Optimum Health staff is well versed in the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS).

CMS determines which services are covered, the value of reimbursements, and the rules related to physician credentialing, contracting and claims processing.

Reimbursements are based on the Medicare Physician Fee Schedule (MPFS) that is published by CMS.

Types of Insurance Payers

The two primary types of health insurance payers are:

➙ Commercial/Private

➙ Government

Types of Insurance Plans

Health Maintenance Organization (HMO)

  • ➙ An HMO delivers health services through a network of providers and facilities
  • ➙ Requires referrals.

Preferred Provider Organization (PPO)

  • ➙ Preferred providers and facilities, but more freedom to choose in or out of network providers.

Exclusive Provider Organization (EPO)

  • ➙ No out of network coverage.

Point-of-Service Plan (POS)

  • ➙ Blends HMO and PPO.
  • ➙ More freedom.


Medicare is a federal government single payer health insurance program for individuals over 65 and younger individuals with disabilities or End-Stage Renal Disease (kidney failure).

Part A

  • ➙ Hospital/SNF/Hospice/Home Health for elderly or people with certain disabilities
  • ➙ In-patient care

Part B

  • ➙ Health insurance for retirement age and disabled – doctor visits, DME, CCM, RPM
  • ➙ Out-patient care

Part C

  • ➙ Medicare Advantage managed care option Parts A and B
  • ➙ PACE – Program of All-Inclusive Care for the Elderly

Part D

  • ➙ Prescription Coverage


Medicaid is a federal healthcare program for low income and disabled that is administered by state governments with federal matching funds. Coverage and benefits vary by state. Federal government sets minimum coverage requirements.