Health Insurance Glossary

Commercial insurance company, a Blue Cross and Blue Shield plan or a Medicare claims agent.
Carve-out Benefits
Coverage stipulating that Medicare-eligible members of a group receive benefits at least equal to benefits received by non-Medicare group members. Members are reimbursed up to the group's contract limitations, less what Medicare paid or would have paid if the member were Medicare-eligible and Medicare were the primary coverage.
Case Management
A coordinated set of activities designed to assist a member in managing specific health care needs.
Certificate of Coverage (COC)
A summary detailing the terms, conditions and limitations of your group coverage that is issued to the group.
See Pre-Authorization.
The amount billed by the provider for the services shown. Some charges from the same provider may be combined.
Treatment of malignant disease by chemical or biological antineoplastic agents. High-dose chemotherapy is a type of chemotherapy often used in conjunction with tissue transplants.
Chiropractic Care
A therapy administered by a licensed Chiropractor that involves manipulation or adjustment of the spine.
Chronic Care
Inpatient or outpatient services provided to patients who suffer from a prolonged illness.
A request for payment for benefits received or services rendered. Either the member or the provider submits claims to the carrier.
COBRA - Consolidated Omnibus Budget Reconciliation Act of 1986
Federal legislation that includes a requirement for groups with 20 or more employees to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage.
The percentage or amount patients are required to pay through their insurance plan for reasonable medical expenses after a deductible has been satisfied.
Local or federal legislation that includes a requirement for groups to offer extended health insurance coverage at the member's expense to members and eligible dependents who leave the group or are otherwise no longer eligible for the group's coverage. See COBRA - Consolidated Omnibus Budget Reconciliation Act of 1986.
Continuity of Coverage
Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.
Methods, drugs or devices for preventing pregnancy.
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.
Contract/Certificate Holder
Group or person to whom a contract or certificate is issued.
Change in a customer's contractual status. For example, transfer from group to direct payment coverage upon termination of employment.
Conversion Option
The choice to purchase individual coverage by a person who is leaving an employee group.
Coordination of Benefits (COB)
Contractual provision which reduces the benefits under one contract to the extent that those benefits are available under a second contract. The purpose is to prevent double payment for one service. See Duplicate Coverage.
The dollar amount a patient pays when services are received. A visit to a primary care physician might require a copayment of $10, a visit to a specialist $20 and a prescription $20.
A term that describes the use of a service or supply which is provided with the primary intent of improving appearance, not restoring bodily function or correcting deformity resulting from disease, trauma or previous therapeutic intervention.
Cost Sharing
Health insurance policy provisions that require insured individuals to pay some portion of covered medical expenses. Examples are deductibles, coinsurance and copayments.
Covered Person
Person, including eligible dependents, entitled to benefits under the contract and also known as the "insured."
Covered Services
Applies to services or supplies specified in the contract for which benefits are available under the member's plan.
Custodial Care
Care which is provided primarily to meet the personal needs of the patient. Custodial Care does not require the continuous attention of skilled medical or paramedical personnel. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care that does not require continuing services of medically trained personnel.