GlossaryHealth InsuranceC
You will find an expanded list and definition of terms in this glossary health insurance C page.
Use it often, especially when you begin to review your health insurance options and benefits.
C
calendar day: Every day of the calendar month, including Saturday,
Sunday, and state and federal holidays. If any action tied to a time frame in an
insurance policy falls on a Saturday, Sunday, or state or federal holiday; then
the action is postponed to the next calendar day that does not fall on a
Saturday, Sunday, or state or federal holiday.
capitation: Fixed monthly fee paid to an insurance company in exchange
for full care of an individual.
case management: A utilization management technique that addresses the
medical necessity of care and alternative treatments or solutions when the
patient is likely to require very expensive treatment.
case manager: A doctor or nurse affiliated with a managed care plan that
arranges and approves medical care for the insured.
catastrophic coverage: This plan pays hospital and medical expenses above
a certain (usually high, i.e., $5,000) deductible. The maximum lifetime limit
may be high enough to cover the cost of a catastrophic illness. Catastrophic
coverage does not pay for doctors visits, routine check-ups or well baby care.
certificate of coverage: A document showing evidence of your
participation in a group health insurance plan.
certificate of creditable coverage: A written statement from your prior
insurance company or health plan documenting the length of time you were
covered.
claim examiner: An insurance company employee/representative who carries
out the claim
examination process. Also known as claim approver, claim analyst, or claim
specialist.
closed panel: A procedure used by Managed Care plan wherein your primary
care physician
makes referrals to other health care providers within the network. This is also
referred to as the
gatekeeper system.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985): A federal
law that requires employers with 20 or more employees to allow eligible employees and
their covered dependents to continue their health insurance coverage, usually for up to 18 months.
The employees pay the premiums (up to 102%) themselves. Eligible employees are those
who have experienced any of the “qualifying events” below:
- termination of employment
- reduction of work hours
- employee's death
- employee's divorce (or legal separation in some states)
- medical entitlement
- change in "dependent" status
coordination of benefits: A method of eliminating duplication of benefits
when you are covered under more than one group plan so that your benefits from
the two plans do not exceed 100% of allowable medical expenses.
commission: The amount of money, usually a percentage of the premiums,
that is paid to an insurance agent for selling an insurance policy.
community rating: The idea that an insurer should charge every insured
the same premium regardless of age, gender, geographic location or health
status.
comprehensive major medical policy: A health insurance policy that covers
both major medical
expenses (i.e., hospitalization and surgeries) and basic medical expenses.
continuing care retirement community: A housing community that provides
different levels of
care from independent living to nursing home.
conversion privilege: A contractual right you have that enables you to
convert to individual
policy when your group coverage terminates, even without providing evidence of
insurability.
covered expenses: Medical services or procedures that the insurance
company agrees to pay
that are listed in the policy.
Most insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay
for mental health care. Covered services are those medical procedures the
insurer agrees to pay for. They are listed in the policy.
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