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| Calendar Year |
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January 1 through December 31 of the same year. Many Deductible amount provisions are on a Calendar Year basis under Major Medical plans. Also, Benefits under basic Hospital surgical and medical plans are usually stated as so much for each Calendar Year.
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| Cancellation |
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Termination of a Policy before its normal expiration date.
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| Capitation (CAP) |
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Capitation represents a fixed monthly dollar amount that a Health Maintenance Organization (HMO) pays to a group of Health Care Providers who have contracted with the HMO. The amount of this fixed dollar amount depends upon the number of HMO Enrollees who have chosen this group of Health Care Providers for "Primary Care" services under the HMO plan. This fixed dollar amount does not vary with how much HMO Enrollees use (or don't use) services offered by this group of HMO Providers. Not all HMO utilize capitation payments.
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| Captive Agents |
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Agents that represent only one Health Plan or insurer.
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| Cardiac Rehabilitation Program |
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An Outpatient program that is supervised by a Health Care Practitioner and directed at improving the physiological well-being of a Covered Person with heart disease
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| Care Plan |
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A written plan for one's health care.
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| Caregiver |
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A person who helps care for someone who is ill, disabled or aged. Some Caregivers are relatives or friends who volunteer their help. Some people provide caregiving services for a fee.
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| Carrier |
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Usually a commercial insurer contracted by the Department of Health and Human Services to process Medicare Part B Claims payments. Also known as Insurance Carrier
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| Carrier Replacement |
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This refers to a situation where one Carrier replaces one or more Carriers.
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| Carry Over Provision |
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In Major Medical policies, allowing an Insured who has submitted no Claims during the year to apply any medical expenses incurred in the last three months of the year toward the new Calendar Year's Deductible.
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| Carve-Out |
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Specialty health service that an MCO obtains for Members by contracting with a company that specializes in that service. See also Carve-Out Companies.
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| Carve-Out Companies |
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Organizations that have specialized Provider Networks and are paid on a Capitation (CAP) or other basis for a specific service, such as mental health, chiropractic, and dental. See also Carve-Out.
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| Case Management |
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A process of identifying plan Members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. Also known as large Case Management (LCM).
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| Case Manager |
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A person, usually an experienced professional (nurse, doctor, or social worker), who coordinates the services necessary under the Case Management approach.
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| Case Mix |
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The number of cases requiring different needs and uses of Hospital resources.
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| Case-Mix Adjustment |
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See Risk-Adjustment.
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| Catastrophe Policy |
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This is an older name for Major Medical. See Major Medical.
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| Catastrophic Coverage - Medicare Part D |
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This is the last portion of Coverage in a Part D plan in which the plan pays almost the entire drug expense for the remainder of the Calendar Year. The portion that the Beneficiary pays during this step is a very small amount of the drug expenses (approximately five percent).
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| Catastrophic Illness |
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A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
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| Catastrophic Limit - Medicare Part D |
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The catastrophic limit is the highest amount of money you'll have to pay out of your own pocket in a year for certain covered Prescription Drug charges.
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| Categorically Needy Individuals |
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Enrollees inMedicaid programs who meet traditionalMedicaid age and income requirements.
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| CCRCs |
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See Continuing Care Retirement Communities (CCRCs).
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| Centers for Medicare and Medicaid Services (CMS) |
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The federal agency overseeing both theMedicare andMedicaid programs. They were made responsible for carrying out the legislation that put the Medicare Part D (Prescription Drug) insurance plans into existence and overseeing how all of the plans conduct business.
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| Centers of Excellence |
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Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants
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| Certificate Holder |
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The person listed on the Benefit Summary as the Certificate Holder.
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| Certificate of Authority (COA) |
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Issued by the state, it licenses the operation of an Health Maintenance Organization (HMO).
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| Certificate of Coverage |
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A document given to an Insured that describes the Benefits, Limitations and Exclusions of Coverage provided by an insurance company.
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| Certificate of Insurance |
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The printed description of the Benefits and Coverage provisions forming the contract between the Carrier and the customer. Discloses what is covered, what is not, and insurance limits.
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| Certificate of Need (CON) |
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Issued by a governmental body. It certifies that the proposed facility will meet the needs of those for whom it is intended. Such need might involve constructing a new health facility, offering a new or different health service, or acquiring new medical equipment.
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| Cestui Que Vie |
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The person whose life measures the duration of a trust, gift, estate, or insurance contract. Thus, in Life and Health Insurance (HI) it is the person on whose life or health the Policy is written, commonly called the Insured, Policyholder, or Policy Owner.
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| CHAMPUS |
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See Civilian Health And Medical Program of The Uniformed Services (CHAMPUS).
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| Chemical Dependency Services |
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The services required in the treatment and Diagnosis of chemical dependency, alcoholism, and drug dependency.
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| Chemical Equivalents |
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Drugs which contain identical amounts of the same ingredients.
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| Children's Health Insurance Program (CHIP) |
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A program, established by the Balanced Budget Act, designed to provide health assistance to uninsured, low-income children either through separate programs or through expanded eligibility under stateMedicaid programs.
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| CHIP |
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See Children's Health Insurance Program (CHIP).
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| Christian Science Organization |
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A religious organization which is certified by the First Church of Christian Scientists. The organization may also beMedicare certified as a Hospital or Skilled Nursing Facility.
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| Chronic Condition |
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Prolonged conditions or illness, such as heart disease, asthma, diabetes.
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| Civilian Health And Medical Program of The Uniformed Services (CHAMPUS) |
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A program of medical Benefits available to inactive military personnel and military spouses, Dependents, and beneficiaries through the Military Health Services System of the Department of Defense. See also TRICARE.
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| Claim |
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An itemized statement of healthcare services and their costs provided by a Hospital, physician's office, or other Provider facility. Claims are submitted to the insurer or Managed Care Plan by either the plan Member or the Provider for payment of the costs incurred.
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| Claim Form |
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An application for payment of Benefits under a Health Plan.
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| Claimant |
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The person or entity submitting a Claim.
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| Claims Administration |
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The process of receiving, reviewing, adjudicating, and processing Claims.
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| Claims Analysts |
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See Claims Examiners.
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| Claims Examiners |
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Employees in the Claims Administration department who consider all the information pertinent to a Claim and make decisions about the MCO's payment of the claim. Also known as Claims Analysts.
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| Claims Investigation |
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The process of obtaining all the information necessary to determine the appropriate amount to pay on a given Claim.
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| Claims Supervisors |
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Employees in the Claims Administration department who oversee the work of several Claims Examiners.
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| Clayton Act |
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A federal act which forbids certain actions believed to lead to monopolies, including (1) charging different prices to different purchasers of the same product without justifying the price difference and (2) giving a distributor the right to sell a product only if the distributor agrees not to sell competitors' products. The Clayton Act applies to insurance companies only to the extent that state laws do not regulate such activities. See also Antitrust Laws.
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| Clinic Model |
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See Consolidated Medical Group.
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| Clinical Integration |
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A type of operational Integration that enables patients to receive a variety of Health Services from the same organization or entity, which streamlines administrative processes and increases the potential for the delivery of high-quality healthcare.
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| Clinical Practice Guideline |
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A Utilization and Quality Management (QM) mechanism designed to aid Providers in making decisions about the most appropriate course of treatment for a specific clinical case.
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| Clinical Status |
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A type of Outcomes Measures that relates to improvement in biological health status.
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| Closed Access |
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A situation where covered insureds must select one Primary Care Physician (PCP). That physician is the only one allowed to refer the patient to other Health Care Providers within the plan. Also called Closed Panel or Gatekeeper Model.
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| Closed Formulary |
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The provision that only those drugs on a preferred list will be covered by a PBM or MCO.
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| Closed Panel |
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See Closed Access.
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| Closed PHO |
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A type of Physician-Hospital Organization (PHO) that typically limits the number of Participating Provider specialists by type of specialty.
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| Closed Plans |
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According to the NAIC's Quality Assessment and Improvement Model Act, Managed Care Plans that require Covered Persons to use Participating Providers.
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| Closed-Panel HMO |
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An HMO whose physicians are either HMO employees or belong to a group of physicians that contract with the HMO.
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| CMP |
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See Competitive Medical Plan (CMP).
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| COA |
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See Certificate of Authority (COA).
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| COB |
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Coordination of Benefits (COB). Also see Nonduplication of Benefits.
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| COBRA |
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A Federal law that gives the right to pay for continued Group health care Coverage for a specified period if the person loses Coverage because of reduced work hours or leaving or loss of a job. Also see Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986.
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| Cognitive Impairment |
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A deficiency in the ability to think, perceive, treason or remember resulting in loss of the ability to take care of one's daily living needs.
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| Coinsurance |
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Coinsurance is the dollar amount or percentage of Covered Charges that must be paid by a Covered Person after any Access Fee, Copayment and Deductible are satisfied. Coinsurance applies separately to each Covered Person, except as otherwise provided in the plan.
Coinsurance only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what any applicable Coinsurance percentage or amount is along with the Covered Charges to which it applies.
This cost-sharing arragement is typically shown as 80%/20% where the Insurance Carrier pays 80% of the Covered Charges and the insured pays 20% of the Covered Charges up to an Out-of-Pocket Limit.
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| Coinsurance Clause |
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A provision stating that the Insured and the insurer will share all losses covered by the Policy in a proportion agreed upon in advance, i.e., 80-20 would mean that the insurer would pay 80% and the Insured would pay 20% of all Covered Charges. See also Percentage Participation.
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| Coinsurance Out-of-Pocket Maximum |
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After this maximum is met, the plan pays 100% of Covered Expenses.
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| Commercial Policy |
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In Health Insurance (HI), this term originally applied to Policy forms intended for sale to individuals in commerce, as contrasted with industrial workers. Currently the term is loosely used to mean all policies that do not guarantee renewability.
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| Common Accident Deductible |
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See Deductible - Common Accident.
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| Common Carrier |
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Means any form of transportation certified for hire to carry passengers.
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| Community Rating |
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A Rating method that sets Premiums for financing medical care according to the Health Plan's expected costs of providing medical Benefits to the community as a whole rather than to any sub-group within the community. Both low-risk and high-risk classes are factored into Community Rating, which spreads the expected medical care costs across the entire community.
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| Community Rating By Class (CRC) |
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The process of determining Premium rates in which a Managed Care Organization (MCO) categorizes its Members into classes or groups based on demographic factors, industry characteristics, or Experience and charges the same Premium to all members of the same class or group. See Adjusted Community Rating (ACR).
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| Compensation Committee |
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Committee of the board of directors that sets general compensation guidelines for a Managed Care Plan, sets the CEO's compensation, and approves and issues stock options.
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| Competitive Advantage |
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A factor, such as the ability to demonstrate Quality, that helps a Managed Care Organization (MCO) compete successfully with other MCOs for business.
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| Competitive Medical Plan (CMP) |
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A federal designation that allows a Health Plan to enter into aMedicare risk contract without having to obtain Federal Qualification as an HMO.
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| Composite Rate |
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One rate for all Members of the Group regardless of their status as single or members of a family.
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| Comprehensive Major Medical |
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A plan of insurance which has a low Deductible, high maximum Benefits, and a Coinsurance feature. It is a combination of basic Coverage and Major Medical Coverage which has virtually replaced separate Hospital, surgical and medical policies with each having its own Deductible requirements. Also see Major Medical Insurance.
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| Concurrent Authorization |
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Authorization to deliver healthcare service that is generated at the time the service is rendered.
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| Concurrent Review |
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Concurrent review involves monitoring the medical treatment and progress toward recovery, once a patient is admitted to a Hospital, to assure timely delivery of services and to confirm the necessity of continued Inpatient Care. This monitoring is under the direction of medical professionals. Concurrent review is a component of Utilization Review (UR).
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| Condition Specific Deductible |
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See Deductible - Condition Specific.
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| Conditional Binding Receipt |
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This is the more exact terminology for what is often called a Binding Receipt. It provides that if a Premium accompanies an application, the Coverage will be in force from the date of application or Medical Examination, if any, whichever is later, provided the insurer would have issued the Coverage on the basis of the facts revealed on the application, Medical Examination and other usual sources of Underwriting information. A Life and Health Insurance (HI) Policy without a Conditional Binding Receipt is not effective until it is delivered to the Insured and the Premium is paid.
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| Conditionally Renewable |
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A contract that provides that the Insured may renew it to a stated date or an advanced age, subject to the right of the insurer to decline Renewal only under conditions stated in the contract.
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| Confining |
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A form of disability or Sickness that confines the Insured indoors, usually at home or in a Hospital. Many policies state that Coverage is afforded only if the Insured is confined.
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| Conflict Of Interest |
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For an MCO board member, a conflict between self-interest and the best interests of the plan.
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| Consolidated Medical Group |
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A large single medical practice that operates in one or a few facilities rather than in many independent offices. The single-specialty or multi-specialty practice group may be formed from previously independent practices and is often owned by a Parent Company or a Hospital. Also known as a Medical Group Practice or Clinic Model.
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| Consolidated Omnibus Budget Reconciliation Act (COBRA) |
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The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires Group Health Plans with 20 or more employees to offer continued health Coverage for employees and their Dependents for 18 months after an employee leaves their job. Coverage may be continued for up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may be continued for up to 36 months in nearly all other cases, such as loss of Dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age. If a former employee opts to continue Coverage under COBRA, the former employee must pay the entire Premium, plus a 2% administration charge.
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| Consolidation |
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A type of Merger that occurs when previously separate Providers combine to form a new organization with all the original companies being dissolved.
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| Continuation |
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Allows terminated employees to continue their Group Health Insurance Coverage under certain conditions.
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| Continuing Care Retirement Communities (CCRCs) |
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Residential communities set up to provide residents with easy Access to health care.
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| Contract Management System |
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An information system that incorporates membership data and reimbursement arrangements, and analyzes transactions according to contract rules. The system may include features such as decision support, modeling and forecasting, cost reporting, and contract compliance tracking.
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| Contract Year |
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The period of time from the Effective Date of the contract to the expiration date of the contract. A Contract Year is typically 12 months long, but not necessarily from January 1 through December 31.
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| Contracted Rate |
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The amount a Health Care Practitioner, facility, or supplier that has a contract with the Insurance Carrier or the Network Manager, as identified for the plan, has agreed to accept as total payment for the treatment, services, or supplies provided.
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| Coordinated Care |
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Links the treatments or services necessary to obtain an optimum level of medical care required by a patient and provided by appropriate Providers. It is also another term for "Managed Care" used by federal government officials.
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| Coordination of Benefits (COB) |
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This occurs when the Insured is covered under more than one plan (for example under a Group plan at work, and as a family member on a spouse's plan) the Benefits from the plans are coordinated so as to limit the total Benefits from all plans. Usually, the Benefits from all plans will not exceed 100% of the covered medical expenses. Also see Nonduplication of Benefits.
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| Copay |
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This is an arrangement where the Covered Person pays a specified amount for various services and the Health Care Provider pays the remainder. The Covered Person usually must pay his or her share when the service is rendered. Similar to Coinsurance, except that Coinsurance is usually a percentage of certain charges where the Copayment is a dollar amount.
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| Copay Provision |
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Often used with Major Medical policies. The Copay provision states what percentage of a Claim the company will pay and what percentage the Insured will pay. For example, an 80 percent Copay provision would provide that the insurer pay 80 percent of claims and the Insured pay 20 percent.
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| Copayment |
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A Copayment is the dollar amount that a Covered Person must pay to a Health Care Practitioner or facility each time certain visits or services are received. This amount does not count toward satisfying any Access Fee, Deductible, Coinsurance or other Out-of-Pocket Limit. Covered Charges in the Medical Benefits section that require a Copayment are not subject to any Deductible.
A Copayment only applies if it is shown in the Benefit Summary. The Benefit Summary will identify what any applicable Copayments are along with the Covered Charges to which they apply. Also known as Copay. For example, a PPO may require a $20 "co-payment" for normal services delivered during a physician Office Visit.
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| Corporation |
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A type of organizational structure that is an artificial entity, invisible, intangible, and existing only in contemplation of the law.
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| Corridor Deductible |
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A Major Medical Deductible that provides for a Deductible, or "corridor," after the full payment of basic Hospital and medical expenses up to a stated amount. In the event of further expenses, payment is on the basis of Participation or Coinsurance, such as 80%-20% or 85%-15%, and the Deductible is that portion paid by the Insured.
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| Cosmetic Procedures |
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Procedures which improve the appearance, but are not medically necessary.
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| Cosmetic Services |
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A surgery, procedure, injection, medication, or treatment primarily designed to improve appearance, self-esteem or body image and/or to relieve or prevent social, emotional or psychological distress.
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| Cost Contract |
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An agreement between a Provider and the Health Care Financing Administration (HCFA) to provide Health Services to Covered Persons based on reasonable costs for service.
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| Cost of Living Benefit |
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An optional Disability Benefit where the monthly Benefit will be increased annually once the Insured is on claim for 12 months.
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| Cost Sharing |
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This occurs when the users of a health care plan share in the cost of medical care. Deductibles, Coinsurance, and Copayments are examples of Cost Sharing.
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| Coverage |
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The Benefits package received from an individual insurance plan. Under Part D, Prescription Drug costs paid by the insurer are the Benefits package, also known as Coverage.
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| Coverage Gap - Medicare Part D |
|
The gap in your Coverage that spans between ordinary drug Coverage and Catastrophic Coverage. In this gap, the Medicare Beneficiary pays 100% of their prescription costs. According to the federal government, about 88% of Medicare beneficiaries who enrolled in a Medicare Part D plan do not have Doughnut (Donut) Hole Coverage. The standard or model Part D Coverage begins with a Deductible of $310 followed by a co-pay of 25% on the next $2520 (you pay $630). Upon reaching the total medication costs of $2830 (with $940 out of pocket), Coverage ceases and the Beneficiary is 100% responsible for all costs during a "blackout period" known as the "Doughnut (Donut) Hole" or "Coverage Gap", until a new spending tier, an additional $3610 out of pocket, is reached and Coverage kicks in again at the "Catastrophic" level. See Doughnut (Donut) Hole.
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| Covered Benefit |
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A health service or item that is included in a Health Plan, and that is partially or fully paid by the Health Plan
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| Covered Charge |
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"An expense that the Insurance Carrier determines meets all of the following requirements:
1. It is Insured for treatment, services or supplies provided by a Health Care Practitioner, facility or supplier.
2. It is Incurred by a Covered Person while Coverage is in force under the plan as the result of a Sickness or an Injury or for preventive medicine services as outlined in the Medical Benefits section.
3. It is Incurred for services or supplies listed in the Medical Benefits section or Outpatient Prescription Drug Benefits section, unless the charges are Incurred during a Benefit Waiting Period.
4. It is Incurred for treatment, services or supplies which are Medically Necessary.
5. It is not in excess of the Maximum Allowable Amount.
Charges from the Covered Person's Nonparticipating Provider may exceed the Maximum Allowable Amount. The Covered Person is responsible for an amounts in excess of the Maximum Allowable Amount, as determined by the insurance carrier."
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| Covered Charges/Expenses |
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Most insurance plans, whether they are PPOs or HMOs, do not pay for all services. Some may not pay for Prescription Drugs. Others may not pay for mental health care.
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| Covered Dependent |
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A person who meets the definition of a Dependent and is eligible to receive Benefits under this plan.
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| Covered Expenses |
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Health care expenses incurred by an Insured or Covered Person that qualify for reimbursement under the terms of a Policy contract.
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| Covered Person |
|
An individual who meets Eligibility Requirements and for whom Premium payments are paid for specified Benefits of the contractual agreement.
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| CRC |
|
See Community Rating By Class (CRC).
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| Credentialing |
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The process of obtaining, reviewing, and verifying a Provider's credentials -- the documentation related to licenses, certifications, training, and other qualifications -- for the purpose of determining whether the Provider meets the MCO's preestablished criteria for Participation in the Network.
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| Credentialing Committee |
|
Committee, which may be a subset of the QM Committee, that oversees the Credentialing process.
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| Credibility |
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A measure of the statistical predictability of a group's Experience.
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| Credit Health Insurance |
|
A Group Disability Income Insurance contract whereby a creditor is protected in the event of the Totally Disabled of a debtor. The Policy will pay Benefits equal to the monthly installment of the debtor.
|
| Credit Insurance |
|
Insurance on a debtor in favor of a creditor to pay off the balance due on a loan in the event of the death or disability of the debtor. Liability Insurance for abnormal loss from bad debts.
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| Creditable Coverage |
|
Any previous Health Insurance (HI) Coverage that can be used to shorten the Pre-Existing Condition - Long Answer Waiting Period. See "HIPAA"
|
| Creditable Coverage - Medicare Part D |
|
A plan other than a Part D plan that offers Prescription Drug Coverage and which meets certainMedicare standards.
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| Critical Access Hospital |
|
A small facility that gives limited Outpatient and Inpatient Hospital services to people in rural areas
|
| Cure Provision |
|
A Provider contract clause which specifies a time period (usually 60--90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.
|
| Current Procedural Terminology (CPT) |
|
A system of terminology and coding developed by the American Medical Association (AMA) that is used for describing, coding, and reporting medical services and procedures
|
| Custodial Care |
|
Care, regardless of setting, that can be performed by persons without professional medical training and that is primarily for the purpose of meeting the personal needs of the patient. Custodial Care:
1. Does not contribute substantially to the improvement of a medical condition according to accepted medical standards; or
2. Is provided primarily to assist in the activities of daily living including, but not limited to, help in walking or getting in or out of bed; assistance with bathing, dressing, feeding, homemaking, or preparation of special diets; or supervision of medication which can usually be self-administered and does not entail or require the continuing services of licensed medical personnel; or
3. Is supportive in nature or primarily for the purpose of providing companionship or ensuring safety.
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