Reimbursement Definitions

6. Charge The maximum amount a health plan agrees to pay for a covered service, regardless of what the provider bills.
10. The component of Medicare that covers outpatient care, doctor visits, and preventive medical services.
11. The set amount a patient must pay out-of-pocket for covered services before insurance begins to share the cost.
14. A private plan alternative to federal Medicare that bundles hospital and medical coverage, often with added benefits and network rules.
15. A status for providers who have negotiated discounted rates with an insurance plan, typically lowering patient expenses.

1. A federal fee-for-service health program allowing patients to visit any approved provider nationwide without network restrictions.
2. A cost-sharing arrangement where the patient pays a percentage of the service cost after meeting the deductible.
3. The portion of Medicare covering inpatient hospital stays, skilled nursing care, and certain home health services.
4. Private insurance designed to cover remaining costs not paid by original Medicare, such as deductibles and coinsurance.
5. A fixed, predetermined fee a patient pays for a specific service at the time of care, independent of the total cost.
7. The annual cap on what a patient must pay for covered services, after which the insurance plan pays 100% of eligible costs.
8. A designation for providers who do not have a contracted rate with an insurance plan, often resulting in higher patient costs.
9. The Medicare benefit that provides coverage specifically for prescription medications through private plans.
12. Cap A limit placed by an insurance plan on the amount or number of services it will cover within a given time period.
13. A provision where specific services or benefits are separated from a standard plan and managed or covered independently.