Health Insurance Terms C

CCRCs
See Continuing Care Retirement Communities (CCRCs).

COB
Coordination of Benefits. See Nonduplication of Benefits.

COBRA
See Consolidated Omnibus Budget Reconciliation Act of 1986.

Calendar Year
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.

Capitation (CAP)
A rate paid, usually monthly, to a health care provider. In return, the provider agrees to deliver the health services agreed upon to any covered person.

Carrier
Usually a commercial insurer contracted by the Department of Health and Human Services to process Part B claims payments.

Carrier Replacement
This refers to a situation where one carrier replaces one or more carriers.

Carry Over Provision
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.

Case Management
The assessment of a person's long term care needs and the appropriate recommendations for care, monitoring and follow-up as to the extent and quality of services to be provided. (H)

Case Manager
A person, usually an experienced professional, who coordinates the services necessary under the case management approach.

Case Mix
The number of cases requiring different needs and uses of hospital resources.

Catastrophe Policy
This is an older name for Major Medical. See Major Medical.

Certificate of Authority (COA)
Issued by the state, it licenses the operation of an HMO (Health Maintenance Organization).

Certificate of Need (CON)
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.

Cestui Que Vie
The person whose life measures the duration of a trust, gift, estate, or insurance contract. Thus, in Life and Health Insurance it is the person on whose life or health the policy is written, commonly called the insured, policyholder, or policy owner.

Chemical Dependency Services
The services required in the treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.

Chemical Equivalents
Drugs which contain identical amounts of the same ingredients.

Christian Science Organization
A religious organization which is certified by the First Church of Christian Scientists. The organization may also be Medicare certified as a hospital or skilled nursing facility.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
Part of the Uniformed Services Health Benefits Program which supplements the medical care available for families of active, deceased, and retired military personnel.

Closed Access
A situation where covered insureds must select one primary care physician. 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.

Cognitive Impairment
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.

Coinsurance Clause
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 losses. See also Percentage Participation.

Commercial Policy
In Health Insurance, 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.

Community Rating
Under this rating system, the charge for insurance to all insureds depends on the medical and hospital costs in the community or area to be covered. Individual characteristics of the insureds are not considered at all.

Competitive Medical Plan (CMP)
This refers to permission given by the federal government that allows an organization to write a Medicare risk contract.

Composite Rate
One rate for all members of the group regardless of their status as single or members of a family.

Comprehensive Major Medical
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. (H)

Concurrent Review
A case management technique which allows insurers to monitor an insured's hospital stay and to know in advance if there are any changes in the expected period of confinement and the planned release date. (H)

Conditional Binding Receipt
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 policy without a conditional binding receipt is not effective until it is delivered to the insured and the premium is paid. (LI,H)

Conditionally Renewable
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.
Confining
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.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986
Legislation providing for a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. 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.

Continuation
Allows terminated employees to continue their group health insurance coverage under certain conditions.

Continuing Care Retirement Communities (CCRCs)
Residential communities set up to provide residents with easy access to health care.

Contract Year
This period runs from the effective date to the expiration date of the contract.

Coordination of Benefits (COB)
See Nonduplication of Benefits.

Coordination of Benefits (COB)
A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy. This provision prevents an insured from receiving claims overpayments.

Copay
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 co-payment is a dollar amount.

Copay Provision
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.

Copayment
See Copay.

Corridor Deductible
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.

Cosmetic Procedures
Procedures which improve the appearance, but are not medically necessary.

Cost Contract
An agreement between a provider and the Health Care Financing Administration to provide health services to covered persons based on reasonable costs for service.

Cost of Living Benefit
An optional disability benefit where the monthly benefit will be increased annually once the insured is on claim for 12 months.

Cost Sharing
A situation where covered persons pay a portion of the health costs such as deductibles, coinsurance, or copayment amounts.

Covered Expenses
Health care expenses incurred by an insured or covered person that qualify for reimbursement under the terms of a policy contract.

Covered Person
A person who pays premiums into the contract for the benefits provided and who also meets eligibility requirements.

Credentialing
This involves approving a provider based on certain criteria to provide or participate in a health plan.

Credit Health Insurance
A group disability income insurance contract whereby a creditor is protected in the event of the total disability 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.

Custodial Care
Care that is primarily for meeting personal needs such as help in bathing, dressing, eating or taking medicine. It can be provided by someone without professional medical skills or training but must be according to doctor's orders. (H)