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Medicare Beneficiary - 42 U.S.C.S. 

Medicare beneficiary ’ means an individual who is enrolled under part B of title XVIII of the Social Security Act.

Medicare beneficiary ’ means an individual who is entitled to benefits under part A of title XVIII of the Social Security Act (42 U.S.C. 1395c et seq.).

Benefit Period

42 U.S.C.S. 

A plan is the pairing of the health insurance coverage benefits under a product and a particular cost-sharing structure, provider network and service area.

The product comprises all plans offered within the product.

The combination of all service areas of the plans offered within a product constitutes the total service area of the product.

Plans within a product can vary based on cost sharing structure, provider network and service area.
Health Plan

A plan is the pairing of the health insurance coverage benefits under a product and a particular cost-sharing structure, provider network and service area.

The product comprises all plans offered within the product.

The combination of all service areas of the plans offered within a product constitutes the total service area of the product.

Plans within a product can vary based on cost sharing structure, provider network and service area.

CCIIO Regs§ 150.103 Definitions.
* * * * *
Individual health insurance policy or individual policy means the legal document or contract issued by the issuer to an individual that contains the conditions and terms of the insurance. Any association or trust arrangement that is not a group health plan as defined in § 144.103 of this subchapter or does not provide coverage in connection with one or more group health plans is individual coverage subject to the requirements of parts 147 and 148 of this subchapter. The term ‘‘individual health insurance policy’’ includes a policy that is –
(1) Issued to an association that makes coverage available to individuals other than in connection with one or more group health plans; or
(2) Administered, or placed in a trust, and is not sold in connection with a group health plan subject to the provisions of parts 146 and 147 of this subchapter.
Merriam Webster: a document that contains the agreement that an insurance company and a person have made
Business DictionaryFormal contract-document issued by an insurance company to an insured. It (1) puts an indemnity cover into effect, (2) serves as a legal evidence of the insurance agreement, (3) sets out the exact terms on which the indemnity cover has been provided, and (4) states associated information such as the (a) specific risks and perils covered, (b) duration of coverage, (c) amount of premium, (d) mode of premium payment, and (e) deductibles, if any.

Read more:

An insurance policy is a contract which outlines an insurer’s obligations to a premium-paying party, known as the policy holder.

What is an Insurance Policy? (with pictures) - wiseGEEK

Insurance Policy — in broad terms, the entire printed insurance contract. Generally, an insurance policy is assembled with a combination of various standard forms, including a declarations page, coverage form, and endorsements. Sometimes a causes of loss form is also required. Together these forms delineate the coverage term, the insurance policy limits, the grant of coverage, exclusions and other limitations of coverage, and the duties and responsibilities of the insured in the event of a loss.

The legal document issued by the company to the policyholder, which outlines the conditions and terms of the insurance; also called the policy contract or the contract


A product is a discrete package of health insurance coverage benefits that is offered using a particular product network type (such as health maintenance organization [HMO], preferred provider organization [PPO], exclusive provider organization [EPO], point of service [POS] or indemnity) within a service area. In the case of a product that has been modified, transferred or replaced, the resulting new product will be considered to be the same as the modified, transferred or replaced product if the changes to the modified, transferred or replaced product meet the standards of 45 CFR §146.152(f), §147.106(e), or §148.122(g) (relating to uniform modification of coverage), as applicable.

Any set of plans that share a network type and a set of benefits is a product.

Limitations on benefit coverage, such as limits based on the frequency of treatment, number of visits, days of coverage or other similar limits on the amount, scope or duration of treatment, which specify the scope of benefits covered rather than the health care provider payment portion owed by the consumer, are considered to be features of a product’s “discrete package of health insurance coverage benefits” rather than a plan’s “cost-sharing structure”.

The definitions of product and plan were updated in the Final Rule Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2018; Amendments to Special Enrollment Periods and the Consumer Operated and Oriented Plan Program published December 22, 2016. See 45 CFR §144.103.


280.3 For the purposes of the Federal Program Inventory, what is a program?
GAO defined program in the Glossary of Terms Used in the Budget Process as an organized set of
activities directed toward a common purpose or goal that an agency undertakes or proposes to carry out
its responsibilities. Within this broad definition, agencies and their stakeholders use the term “program”
in different ways. Agencies have widely varying missions and achieve these missions through different
programmatic approaches, so differences in the use of the term “program” are legitimate and meaningful.
For this reason, this guidance does not prescribe a superseding definition of “program”; rather, consistent
with the GPRA Modernization Act, agencies may identify programs consistent with the manner in which
the agency uses programs to interact with key stakeholders and to execute its mission.

OMB Circular No. A–11 (2015)
AO-05-734SP A Glossary of Terms Used in the Federal Budget Process

General wellness program, asthmatic child program

Example:  Medicare, Medicaid, TriCare, State level services like Family Care which is paid with state or local funding

6/1 notes: separate difference between state/federal organization level (e.g. Medicare) and a plan benefit offering level (e.g. wellness program


29 CFR § 825.125 - Definition of health care provider.

Entitlement Programs

Entitlement programs. Eligibility is based upon prior contributions from payroll taxes. The four major U.S. entitlement programs in the United States are Social Security, Medicare, unemployment insurance, and worker’s compensation. 
Welfare Programs

Welfare programs are government subsidies to the poor.

There are six major U.S. welfare programs. They are Temporary Assistance for Needy Families, Medicaid, Food Stamps, Supplemental Security Income, Earned Income Tax Credit, and Housing Assistance.

Welfare programs are based on a family's income. To qualify, their income must be below an income based on the federal poverty level.

The federal government provides the funding, while states administer them and provide additional funds. When the federal government reduces funds without lowering the states' responsibilities, it creates an unfunded mandate.

FHIR Coverage.payor

Issuer of the policy
The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.

*Does 'payor' here include third-party administrators?

X12 837 - Definition of 'the payer'

'The payer is a third-party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, TRICARE, etc.) or an entity such as a third party administrator (TPA), repricer, or third party organization (TPO) that may be contracted by one of those groups.' - WPC © 2006 Copyright for the members of ASC X12N by Washington Publishing Company

ASC X12N/005010X222

ASC X12 Standards for Electronic Data Interchange

1.4 Business Usage


one that pays

especially : the person by whom a bill or note has been or should be paid

AMA on Payer vs Payor 

...a site-specific advanced Google search of JAMA reveals AMA's preference.
payer = 1240 hits (wins!)
payor = 46 hits


Patient Navigator Training Collaborative

Healthcare costs are paid for by private payers or public payers. Private payers are insurance companies and public payers are federal or state governments.

A private payer is a private insurance company.

RxBin - Stands for bank identification number, though it doesn't involve banks and is used to accurately route claims to pharmacy benefit managers (PBM).

The pharmacy industry uses RxBin (required), RxPCN (situational) and RxGrp (situational) to identify pharmacy benefit plans.

RxBIN and RxPCN is analogous to the U.S. zip code + 4. RxBIN (or BIN number), is like the 5-digit zip code that determines the routing destination, and RxPCN (or processor control number), is like the +4, providing a more specific destination.

NCPDP Processor ID Number (BIN) is a six-digit number that health plans use to process electronic pharmacy claims if the health plan doesn't use pharmacy benefit cards with a magnetic stripe. Plans that use cards with a magnetic stripe should use the recommended American National Standards Institute (ANSI) Issue Identifier Number (IIN) for processing electronic pharmacy claims. ANSI issues IIN numbers. NCPDP issues the Processor ID Number (BIN).

Prescription drug routing information, known as 4Rx data, are the four data elements used to process a pharmacy claims.

In Medicare Part D, these four elements uniquely identify the Medicare Part D Sponsor for the beneficiary and are identified by the sponsor during beneficiary enrollment.

The set of four elements are exchanged with CMS contracted entities during eligibility verification, claims processing, and information reporting transactions, as well as post adjudication claim reporting functions.

The 4Rx data are: RxBIN, RxPCN, RXGRP & RxID. 4Rx data allows payment on behalf of the beneficiary to be counted toward TrOOP. (True Out-of-Pocket costs paid by a beneficiary or others on the beneficiary’s behalf that accumulate towards the annual out-of-pocket threshold)



NCPDP Guidance Documents:

NCPDP Pharmacy Card Fact Sheet:

Mapping NCPDP Pharmacy Card to X12N 270/271 (eligibility):

NCPDP Medicare Part D Resources:


Note:  NCPDP defines a processor as: An insurer, a governmental program or another financially responsible entity or a third-party administrator or intermediary contracted on the behalf of those entities which receives prescription drug claims, makes a decision regarding the level of reimbursement to the provider, and transmits a response to the provider submitting a claim.

The PCN appears on the pharmacy ID card with the BIN/IIN in accordance with rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. This document is available with NCPDP membership. General information is available on the Guidance Documents page under the "Pharmacy and Healthcare Identification Cards" banner.

Not all entities use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation.


For members who have Medicare part D, this is the patient's member number in the PBM’s system that processes claims

Types of Insurance



 The type of coverage: social program, medical plan, accident coverage (workers compensation, auto), group health or payment by an individual or organization.

Focus on Healthcare

Mary Kay







(includes Dental, Vision)

Home Owner/ Residential


Life & Annuity




(Excessive Loss)



Worker's Compensation

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