Understanding Pre-Payment Health Plans

Posted on October 2, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

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Classic: A pre-payment plan refers to health insurance plans that provide medical or hospital benefits in service rather than dollars, such as the plans offered by various Health Maintenance Organizations. A method providing in advance for the cost of predetermined benefits for a population group, through regular periodic payments in the form of premiums, dues, or contributions including those contributions that are made to a health and welfare fund by employers on behalf of their employees!

Modern:  A Prepaid Group Practice Plan specifies health services are rendered by participating physicians to an enrolled group of persons, with a fixed periodic payment made in advance by (or on behalf of) each person or family. If a health insurance carrier is involved, a contract to pay in advance for the full range of health services to which the insured is entitled under the terms of the health insurance contract.

Examples:

  • Pre-Paid Hospital Service Plan: The common name for a health maintenance organization (HMO), a plan that provides comprehensive health care to its members, who pay a flat annual fee for services.
  • Pre-Paid Premium: An insurance or other premium payment paid prior to the due date. In insurance, payment by the insured of future premiums, through paying the present (discounted) value of the future premiums or having interest paid on the deposit.
  • Pre-Paid Prescription Plan: A drug reimbursement plan that is paid in advance.

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MEDICAL EXPENSES: Out of Pocket and Out of Network Fees

Posted on September 9, 2025 by Dr. David Edward Marcinko MBA MEd CMP™

By A.I. and Staff Reporters

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OUT OF POCKET [OOP] EXPENSES

Classic: The portion of medical expenses a patient is responsible for paying.

Modern: Refers to the maximum you will pay during your policy period, which is typically a year, before your plan starts to pay 100% of your allowed amount. The costs of your deductible, co-pay, and co-insurance are included here, but not your premium.

CO-PAYS: https://medicalexecutivepost.com/2025/05/17/cleveland-clinic-controversial-new-health-insurance-co-payment-policy/

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OUT OF NETWORK [OON] EXPENSES

Classic: “Out-of-network” health care providers do not have an agreement with your insurance company to provide care. While insurance companies may have some out-of-network benefits, medical care from an out-of-network provider will usually cost more out-of-pocket than an in-network provider. 

Modern: The amount that a health care insurance plan will contribute toward out-of-network services will vary by your insurance company and is often based on a “reasonable and customary” amount that the service should cost

Example: If you go to an out-of-network dentist and are billed $300 for the service, your insurance company may contribute $200 toward paying this cost because $200 is the amount it has decided is “reasonable and customary” for this service. When out-of-network, any remaining cost above this amount ($100 in this case) may have to be fully covered by the person receiving care. When out-of-network, the usual coinsurance rates that apply in-network may not apply out-of-network. Additionally, out-of-network service costs may not count toward an annual deductible.

CHARGE-MASTER: https://medicalexecutivepost.com/2024/11/20/charge-master-medical-bills-paradox/

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DAILY UPDATE: PBMs Scrutinized as Companies Report and Stock Markets Rotate

Posted on July 16, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

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Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“

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Though the accountant shortage is still a concern, a shortage of AI and tech skills might be a more pressing issue right now. That’s according to a pulse survey by consulting firm RGP and YouGov, which polled 213 US financial professionals at the director level and above this June.

Read: What do you do when you hit your insurance deductible? Some people throw parties. (the New York Times)

CITE: https://www.r2library.com/Resource

Here’s where the major benchmarks ended:

  • The S&P 500® index (SPX) rose 15.87 points (0.28%) to 5,631.22; the Dow Jones Industrial Average® ($DJI) climbed 210.82 points (0.53%) to 40,211.72, a new record-high close; the NASDAQ Composite® ($COMP) added 74.12 points (0.4%) to 18,472.57. 
  • The 10-year Treasury note yield (TNX) gained four basis points to just below 4.23%.
  • The CBOE Volatility Index® (VIX) increased to 13.14, its highest close since June 24.

What’s up

  • Bitcoin-related stocks rose alongside the crypto rally today, with Coinbase up 11.39% and Microstrategy climbing 15.36%.
  • Gun manufacturers always rise after a major shooting incident, and the assassination attempt on Donald Trump certainly meets that criteria. Sturm, Ruger & Company jumped 5.44%, and Smith & Wesson rose 11.38%.
  • Stelco Holdings rocketed 73.98% higher on the news that the Canadian steelmaker will be acquired by Cleveland Cliffs for $2.8 billion.
  • AutoNation popped 2.01% on the news that it’s cutting $1.50 off of its EPS for the latest quarter due to the CDK cyberattack. Apparently getting ahead of the bad news is actually good news?

What’s down

  • Macy’s sank 11.76% after the department store’s board voted to end acquisition negotiations with activist investors Arkhouse and Brigade.
  • Burberry fell 16.08% after a poor quarterly report, a profit warning, and the ousting of its CEO.
  • AES plummeted 10.01% thanks to a storm cutting power to thousands of the utility company’s customers throughout Ohio.
  • SolarEdge Technologies dropped 15.36% after the company announced it will lay off 400 employees to improve profitability. Shares of solar competitors slumped in sympathy: First Solar fell 8.50%, Sunrun sank 8.95%, and Sunnova Energy fell 9.96%.

CITE: https://tinyurl.com/2h47urt5

The Federal Trade Commission (FTC) frequently sets its sights on healthcare, which has previously included efforts to crack down on data privacy and ban noncompetes in contracts. Lately, the agency has turned its attention to pharmacy benefit managers (PBMs)—the groups that negotiate drug prices between insurers and pharmaceutical manufacturers—to shed light on how they impact the healthcare industry.

CITE: https://tinyurl.com/tj8smmes

Stat: 23.5%. That’s how much Covid-related emergency room visits increased in a week at the beginning of this month. (CDC)

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PODCAST: Healthcare Costs are Crazy!

Posted on March 28, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Eric Bricker MD

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PODCAST: Health Insurance Plans Confusing and Largely Misunderstood

Posted on April 28, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

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By Eric Bricker MD

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According to One Survey, only 4% of People Understand the Basic Insurance Terms of Deductible, Co-Insurance, Copay and Out-of-Pocket Maximum.

In Another Survey by United Healthcare Itself, Only 9% Understood the Terms Premium, Deductible, Co-Insurance and Out-of-Pocket Max.

This Lack of Understanding is Not the Fault of the Employee Benefits Professionals or the Employees… Rather, the Health Insurance Plan Designs Are Just Too Complicated.

CITE: https://www.r2library.com/Resource/Title/082610254

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PODCAST: https://www.youtube.com/watch?v=Yp6TI7iu-m0

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On Health Insurance Premiums and Deductibles RISING!

Posted on March 19, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

 

2020 Employer Health Benefits Survey – Summary of Findings

Filed under: Health Economics, Health Insurance, iMBA, Inc. | Tagged: , , | 1 Comment »

About the Healthcare Blue Book Consumer Website

Posted on November 11, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Establishing Price Transparency for Medical Goods and Services

By Staff Reporters

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The website Healthcare Blue Book http://www.healthcarebluebook.com is provided free to consumers. The site presents a reported fair price to pay for a healthcare service or medical product when the patient is paying cash at the time of treatment; adjusted for geography and zip codes. It reports to represent a payment amount that many high-quality providers accept from insurance companies as payment in full, and it is usually less than the stated “billed charges” amount.

Comparison Shopping

Unfortunately, it is difficult for consumers to determine fair pricing for healthcare. Prices are not generally published and the list prices (or billed charges) are higher than providers typically charge most of their patients with insurance. The Healthcare Blue Book is a free resource that shows a fair price for healthcare products and services to consumers.

The Consumer Need to Know

Consumers with traditional health insurance frequently need to know how much healthcare services will cost. Average deductibles are increasing and can be $1,000 or higher. Coinsurance rates, which are the percentage of the bill that the consumer must pay, range from 20 to 40%. Many consumers would prefer to use the doctor of their choice, instead of the one selected as “in-network” by their insurance company, as long as they knew they wouldn’t have to pay higher prices.

Assessment

There are also “non-covered services” that may not be covered by insurance. As health insurance companies shift more of the cost to consumers, consumers need to be able to choose healthcare services at fair prices.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Give em’ a click http://www.healthcarebluebook.com and tell us what you think? As a physician or medical provider are you intimidated by this site and resulting price transparency? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com and http://www.springerpub.com/Search/marcinko

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