Insurance plan types, prior authorization, and reimbursement models tested on the CCM certification exam.
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- What is an HMO (Health Maintenance Organization) plan known for requiring?
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A primary care physician (PCP) referral to see specialists, with little to no out-of-network coverage- Does a PPO (Preferred Provider Organization) plan require a PCP referral to see a specialist?
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No, referrals are not required- What happens if a PPO member sees an out-of-network provider?
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The plan still covers care, but at a higher cost share than in-network- What is a key feature of an EPO (Exclusive Provider Organization) plan?
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It covers only in-network care, except in emergencies, but usually does not require referrals- What best describes a POS (Point of Service) plan?
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A hybrid plan requiring PCP referrals like an HMO, but allowing out-of-network care at higher cost like a PPO- What is a High Deductible Health Plan (HDHP) typically paired with?
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A Health Savings Account (HSA)- What is an indemnity (fee-for-service) health plan?
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A plan that lets the member see any provider and reimburses a set percentage of billed charges- Define deductible in health insurance.
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The amount a member must pay out of pocket before the insurance plan begins to pay- Define copayment (copay).
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A fixed dollar amount a member pays for a covered service at the time of care- Define coinsurance.
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The percentage of a covered service's cost that the member pays after meeting the deductible- Define out-of-pocket maximum.
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The most a member has to pay for covered services in a plan year, after which the plan pays 100 percent- Define premium in health insurance.
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The amount paid, usually monthly, to keep a health insurance policy active- Define prior authorization.
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Approval from the health plan required before a specific service, procedure, or medication will be covered- What is the main purpose of prior authorization?
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To confirm medical necessity and control costs before a service is rendered- In ____, a case manager evaluates the medical necessity of care while the patient is still receiving treatment, such as during a hospital stay.
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