A term that describes a shared payment between an insurance company and an insured individual. Under many plans, co-payments are made at the time of the service and the health plan pays for the remainder of the fee. What services the health plan does and does not pay for. What the insurance company will consider paying for as defined in the contract. For example, under some plans generic prescriptions are covered expenses while brand name prescriptions are not.
Deductibles are standard in many policies, and are usually based on a calendar year.
The hospital classification and reimbursement system that groups patients by diagnosis, surgical procedures, age, sex and presence of complications. This is a financing mechanism used to reimburse hospital and selected other providers for services rendered. Criteria for provider participation may be the same of those in PPOs but have a more restrictive provider selection and credentialing process. A traditional health care payment system in which physicians and other providers receive payment based on each billed charge for a visit or service rendered. An organization that provides, offers or arranges for a wide range of covered health care services for a specified group of enrollees for a fixed, periodic prepayment.