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Payor Mix Catagories
| Payor Type |
Description |
Medicare |
Medicare is a type of insurance for those patients 65 years and older, for some patients with disabilities regardless of age and for patients with End Stage Renal Disease (kidney failure requiring dialysis.) Medicare is Federal healthcare insurer or payer. To learn more about Medicare, click here. |
| Medicaid |
Medicaid is a government assistance program, providing healthcare to people with very limited income. While the requirements for Medicaid vary from state to state, they are often similar to that state’s requirements for granting individuals public assistance (welfare). Click here for more information about Medicaid.
An important point to remember about Medicaid is that a facility must meet specific institutional standards and be certified for Medicaid in order to be paid through Medicaid. |
| Tricare |
Tricare is an insurer or payor for military service members and their families. |
| Managed Care Discounted (FFS) |
FFS means fee for service. It is a contract between a hospital and insurance company, which is similar to the arrangement hospitals have with Medicare and Medicaid. The payor and the hospital negotiate a price, which is less that the full price the hospital would normally charge. The hospital agrees to accept for service performed on that payor’s patients. |
| Managed Care Capitatied |
A contract to accept a PMPM (per member per month) cash rate per member for all healthcare costs for these members. |
| Commercial |
In the healthcare industry commercial insurance means many different things. Usually, commercial insurance refers to any kind of private insurance. Private insurance is anything not administered by the government, for example CIGNA, Blue Cross/Blue Shield or Aetna.
In this rotation however, commercial insurance is the ultimate insurance policy. It does not involve a negotiated fee for each service, but instead pays 100% of billed charges for the patient. |
| Self-pay |
Self-pay payors are paying their own medical bills with their own money. Patients who are self-pay may be independently wealthy, but more likely, they cannot afford health insurance, but do not qualify for Medicaid. As mentioned above, the requirements to receive Medicaid are usually similar to those to receive welfare assistance. So what kind of person would fail to qualify for Medicaid? One example might be a patient who is employed making minimum wage. Her employer doesn’t provide health insurance and she makes too much money to qualify for Welfare and Medicaid, but cannot afford to buy her own insurance. |
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