The following programs are typically included in TRICARE medical management efforts:
Natalie Chan is a member of the Ultra Health Plan, a health plan. Whenever she needs nonemergency medical care, she sees Dr. David Craig, an internist. Ms. Chan cannot self-refer to a specialist, so she saw Dr. Craig when she experienced headaches. Dr. Cr
One distinguishing characteristic of a health maintenance organization (HMO) is that, typically, an HMO
Many HMOs are compensated for the delivery of healthcare to members under a prepaid care arrangement. Under a prepaid care arrangement, a plan member typically pays a
Individuals can use HSAs to pay for the following types of health coverage:.
Ronald Canton is a member of the Omega MCO. He receives his nonemergency medical care from Dr. Kristen High, an internist. When Mr. Canton needed to visit a cardiologist about his irregular heartbeat, he first had to obtain a referral from Dr. High to see
One way in which a health plan can support an ethical environment is by
Phillip Tsai is insured by both a indemnity health insurance plan, which is his primary plan, and a health plan, which is his secondary plan. Both plans have typical coordination of benefits (COB) provisions, but neither has a nonduplication of benefits p
One component of information systems used by health plans incorporates membership data and information about provider reimbursement arrangements and analyzes transactions according to contract rules. This information system component is known as
Katrina Lopez is a claims analyst for a health plan that provides a higher level of benefits for services received in-network than for services received out-of-network. Ms. Lopez reviewed a health claim for answers to the following questions:
Question A —
