GLOSSARY OF HEALTH INSURANCE TERMS

C

Calendar Year Deductible — a deductible that applies to any eligible medical expenses incurred by the insured during any one calendar year.

Capitation — a set amount of money received or paid out to a health provider. It is based on membership rather than on the medical services delivered and usually is expressed in units of per member per month.

Carryover Deductible —the deductible payable under continuation coverage includes the portion of the deductible satisfied before the qualifying event.

Carve-Out — a program separate from the primary group health plan designed to provide a specialized type of care, such as a mental health carve-out. Also, a method of integrating Medicare with an employer's retiree health plan (making the employer plan excess or secondary) which tends to produce the lowest employer cost.

Case Management — a utilization management technique that focuses on coordinating a number of health care and disability services needed by clients. It includes a standardized, objective assessment of client needs and the development of an individualized service or care plan that is based on the needs assessment and is goal-oriented. Often used for patients with certain conditions who need extensive medical services; usually overseen by an individual or team of medical practitioners.

Cash Balance Plan — a defined benefit plan that simulates a defined contribution plan. Benefits are definitely determinable, but account balances are credited with a fixed rate of return and converted to a monthly pension benefit at retirement.

Catastrophic Coverage — health care for life-threatening conditions whose cost can drain an individual's family income.

Certificate of Creditable Coverage —notes the amount of previous qualified health coverage; required by the Health Insurance Portability and Accountability Act (HIPAA) in certain circumstances.

Centers for Disease Control (CDC) — the federal agency that researches and investigates causes of diseases, provides educational and prevention programs, and issues definitions of diseases and the conditions that determine eligibility for state, federal and/or private benefit programs. CDC is part of the Public Health System, a division of the Department of Health and Human Services.

Centers for Medicare/Medicaid — the agency of the Department of Health and Human Services that administers Medicare, Medicaid and other federal programs established by the Social Security Act of 1935. Formerly the Health Care Financing Administration (HCFA).

Chiropractor — (doctor of chiropractic) a licensed health professional (not a physician) who has extensive training and treats diseases caused by malfunction of the nerve system using manipulation and other treatments most commonly of the spine and pelvis.

CNA — certified nursing assistant.

COBRA — Consolidated Omnibus Reconciliation Act. A portion of this Act requires employers to offer the opportunity for terminated employees to purchase continuation of health care coverage under the group's medical plan.

Coinsurance — a provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid out of pocket by the member.

Coordination of Benefits (COB) — a group health insurance policy provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is insured under two contracts.

Copayment — that portion of a claim or medical expense that member must pay out of pocket. Usually a fixed amount, such as $10 in many HMOs.

Coronary Care Unit (CCU) — a unit of a hospital, usually part of ICU, especially designed and staffed to care for critically ill patients with heart attack or disease or following heart surgery.

Credentialing — refers to the obtaining and reviewing the documentation of professional providers by a health plan. The documentation includes education, licensure, certifications, insurance, evidence of malpractice insurance and malpractice history.

Custodial Care — general assistance in performing the activities of daily living, as well as board, room and other services, generally provided on a long-term basis and that does not include any skilled nursing components.