Page tree

Versions Compared

Key

  • This line was added.
  • This line was removed.
  • Formatting was changed.

...

Beneficiary

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 Period42 U.S.C.S. 
PlanA 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
144.103
Health PlanA 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
144.103
Policy§ 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.
CCIIO
ProductA 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.

Program280.3 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)
AND/or
AO-05-734SP A Glossary of Terms Used in the Federal Budget Process
Provider

29 CFR § 825.125 - Definition of health care provider.



Entitlement ProgramsEntitlement 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 ProgramsWelfare 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.
https://www.thebalance.com/welfare-programs-definition-and-list-3305759
Payor/Payer

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?

https://www.hl7.org/fhir/coverage-definitions.html#Coverage.payor

X12 837 - Definition of 'the payer'*Can we quote the ASC X12 standard directly here?

'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

Merriam-Webster

one that pays

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

https://www.merriam-webster.com/dictionary/payer

AMA on Payer vs Payor 

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

http://amaediting.blogspot.com/2008/08/payer-vs-payor.html
Payers

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. 

http://www.patientnavigatortraining.org/healthcare_system/module2/3_healthinsurancepayersplans.htm

...