Type of managed care organization (MCO) that will pay for all of the enrollees’ (members’) medical care costs in return for a monthly premium, plus any applicable deductible or copayment. The HMO will pay for all hospital costs (generally referred to as Part A ) and physician costs (generally referred to as Part B ) that it has arranged for and ordered. Like a health care prepayment plan (HCPP), except for out-of-area emergency services, if a Medicare member (enrollee) chooses to obtain services that have not been arranged by the HMO, he or she is liable for any applicable deductible and coinsurance amounts, with the balance to be paid by the regional Medicare fiscal intermediary and/or carrier.

Insurance payment that is based on the cost of health care services in which allowable costs are determined by the insurer. This method is used by some insurance plans or programs but is being replaced by prospective payment. Also called cost-related reimbursement.

Evaluation method that measures the insurance program’s economic benefits to the program’s medical care over a period of time expressed in dollar amounts. This is done to see if future health care costs can be reduced and earnings increased because of improved health of the members of a health plan.
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Procedure for comparing the costs of any proposal with the benefits of that proposal, in order to determine the proposal’s relative value.

To increase monthly benefits in disability income benefit, pension benefit, or life income benefit to make up for a change in the cost of living. Also known as cost of living rider.

Discussion between the physician and a patient, family, or both concerning the diagnosis, recommended studies or tests, treatment options, risks, benefits of treatment, patient and family education, and so on. See also E/M counseling and psychiatric counseling.

Person who assists the patient by obtaining information and identifying the amount that health insurance pays for a specific medical service and determines the amount the patient is responsible for paying. Also known as patient account representative or patient service representative .

Blank check in which the name of the bank and account number is filled in with ink or typed by the maker.