Calendar-Year Deductible – During a calendar year (January – December), amount that an insured (member) is responsible for before the insurance starts paying covered expenses, excluding copays, coinsurance, and noncovered expenses. The process of meeting the deductible, before insurance pays, starts over each January 1.
Capitation – Capitation is when an insurance company pays providers a flat fee per patient rather than a fee per service. HMOs often use the capitation approach.
Carrier – A carrier is an insurer, group hospital plan, or managed care organization that offers health insurance plans.
Carry-Over Provision – Some health insurance plans allow a covered person to carry over into the next year expenses paid for care received in the last three months of the year. These expenses can be applied to the next year’s deductible.
Case Management – When a covered person needs a lot of medical care, a case manager may be assigned by the health insurance company which is then considered as case management. The case manager will work with the covered person’s providers to coordinate care. The manager also makes sure the covered person’s plan is being properly and fully utilized.
Certificate of Coverage – Certificate of coverage is a document from the insurance company that describes a covered person’s coverage benefits, limitations, and exclusions.
Chronic – A condition is considered chronic when it’s permanent, recurring, or long lasting.
Claim – A claim is a request to an insurer for payment for medical services provided. With managed care plans, providers commonly submit claims to the insurance company. See Managed Care.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) – COBRA is a federal law that allows most laid off workers to maintain their employer-sponsored health plan. The terminated employee is responsible for the full insurance premium (includes the portion paid by former employer). COBRA coverage is temporary – normally 18 months. There are exceptions, but generally COBRA covers workers in firms with at least 20 employees. COBRA applies to terminated (voluntary and involuntary) workers for reasons other than gross misconduct and those impacted by a reduction in hours of employment.
Coinsurance – Coinsurance is the amount that you are obligated to pay for covered medical services after you’ve satisfied any required deductible. Coinsurance is typically expressed as a percentage of the covered amount for a service rendered by a health care provider.
Coinsurance Out-of-pocket Maximum – The Coinsurance out-of-pocket maximum is the limit on the amount you pay for covered health services (during the calendar year for most plans), after you have paid your deductible and excluding any copays. Plans generally pay all covered costs (except copays) for the rest of the year after you reach this limit. This limit includes only amounts paid for covered services. For example, out-of-network reductions or claims for cosmetic treatment do not count toward the coinsurance out-of-pocket maximum. Amounts in excess of the non-network reimbursement amount also do not apply to the coinsurance out-of-pocket maximum.
Complications of Pregnancy – Severe conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and elective caesarean section aren’t complications of pregnancy.
Coordination of Benefits (COB) – Coordination of benefits is the method of integrating benefits payable under more than one health insurance plan, so that the insured’s benefits from all sources do not exceed 100 percent of allowable medical expenses.
Copayment – Copayment is often referred to as “copay”, a fixed-dollar amount an insured is required to pay to receive services, e.g., $35 for a doctor’s visit, $15 for a prescription. Normally, doctor visit services subject to a copayment are not subject to a deductible (check your plan for details). Prescription drug copays may first require a deductible to be met.
Covered Amount – Covered amount is the amount remaining after subtracting any discount and/or non covered amounts. This amount is used for calculating benefits (subject to deductible, copay and coinsurance percentage).
Covered Expense – Covered expense is an expense that will be applied to the deductible or reimbursed according to the terms of the insurance plan.
Critical Illness Insurance – Critical Illness insurance is a type of insurance designed to pay a policyholder a single cash payment when the person or their spouse is diagnosed with a major illness. The money can be used for both living and medical expenses.