Lesson 12 Review
Service providers have subscribers rather than policyholders. The service approach is used primarily by two types of organizations: (1) Health Maintenance Organizations (HMOs) and (2) Preferred Provider Organizations (PPOs).
An HMO is NOT insurance - It is a maintenance contract on the insured's well-being. HMOs must hold an open enrollment period of not less than 30 days during every 18-month period.
The Reimbursement Approach means health care is provided first and then the charges are submitted to the insurer for reimbursement. The Right of Assignment allows policyowners to assign benefit payments from the insurer directly to the health care provider.
HMOs are required to file a report of activities within three months of the end of each fiscal year. A complete examination of an HMO's affairs is conducted at least every five years.
Every HMO subscriber must receive a benefits package that includes a copy of the HMO contract and certificate and a member's handbook.
The purpose of Florida's Health Maintenance Organization Act is to increase efficiency and economy in the delivery of health care.
There is no Florida law stating that maternity benefits must be offered under an HMO. However, if it is offered, the length of stay for in-hospital benefits cannot be limited.
The penalties in Florida for violating the Unfair Trade Practices Act are probation, suspension, or revocation of licensure or HMO Certificate of Authority and a fine up to $200,000. If the infraction is a criminal violation, penalties can result in imprisonment.
If a subscriber is covered under a plan that provides for optional family coverage, any newborn of the member must be covered at birth until 18 months of age.
HMOs are required by law to hold an open enrollment period of not less than 30 days every 18-month period. New dependents are eligible to enroll within 30 days of marriage, birth, or adoption (applies to group, small group, and HMO group policies only.)
PPOs operate on a fee for services rendered basis rather than prepaid plans like HMOs. Groups that contract with PPOs are employers, insurance companies, or other health insurance benefits providers and members select from among the plan's preferred providers for services.
Medicare Part A provides hospital coverage, Medicare Part B provides medical coverage, Medicare Part C provides new options, and Medicare Part D covers prescription drugs.
Medicare supplement policies (and long-term care policies) have a free look period of 30 days rather than the customary 14-day free look period.
Medicare patients have a lifetime reserve of 60 days of hospital coverage.
PPOs who participate in Medicare coverage services do not require PCP referral.
Medicare Part D beneficiaries in 2012 pay a monthly premium and an annual deductible. Once the annual deductible is satisfied, beneficiaries are responsible for 25% of prescription drug costs and Medicare will pay the other 75%, and coverage then stops completely.
In order to qualify for Medicaid benefits, the applicant must able to prove they do not have the ability or means to pay for their own medical care. Individuals must also be at least age 65, blind, or disabled, be a U.S. citizen or permanent resident alien, need the type of care that is provided only in a nursing home, and meet certain asset and income tests.
The Deficit Reduction Act helps restrain Medicaid spending. The design plan is to encourage preventive health care (like HMOs) among beneficiaries and to choose lower-cost alternatives for equivalent care.
Workers' compensation insurance provides injured workers with medical care expenses, disability income, and rehabilitation benefits if injured in the workplace, no matter who is at fault. Individual states govern their own workers' compensation laws.
METs are an alternative form of group coverage used for small group employers.
In the MEWA, a number of employers pool their risks, self-insure, and attain tax-exempt status. Employees are required by law to have an "employment-related common bond."
The information contained in Units 16 and 20 of the Florida study manual has been presented in Lesson 12 of the online course.
