Coordination of Benefits. See Nonduplication of Benefits.
See Consolidated Omnibus Budget Reconciliation Act of 1986.
January 1 through December 31 of the same year. Under major medical plans, many deductible amount provisions are on based a calendar year. Benefits under basic hospital surgical and medical plans are based on an amount per calendar year.
A rate paid to health care provider, usually monthly. The provider agrees to deliver health services as agreed upon to covered person.
Commercial insurer contracted by the Department of Health and Human Services to process payment of Part B claims.
A situation where one carrier replaces another carrier or carriers.
Carry Over Provision
For major medical policies, an insured who has submitted no claims during the year can apply any medical expenses incurred in the last three months of the year toward the next calendar year's deductible.
Assessment of a person's long term care needs and follwed by appropriate recommendations for care, monitoring and follow-up as applies to extent and quality of services to be provided.
Person, usually experienced professional, who coordinates services necessary for case management approach.
Number of cases requiring different hospital resources.
An older name for Major Medical.
Certificate of Authority (COA)
State issued licensing the operation of an HMO (Health Maintenance Organization).
Certificate of Need (CON)
Government issued certification that the proposed facility meets the needs of those for whom it is intended. The need may involve constructing a new health facility, offering new or different health services, or acquiring new medical equipment.
Cestui Que Vie
Person whose life is the measurement of the duration of a trust, gift, estate, or insurance contract. In Life and Health Insurance defines it as the person on whose life or health the policy is written, referred to as the insured, policyholder, or policy owner.
Chemical Dependency Services
Services required for treatment and diagnosis of chemical dependency, alcoholism, and drug dependency.
Situation in which covered insureds must select a sole primary care physician. This physician is the only one to refer the patient to other health care providers within the plan. Also called Closed Panel or Gatekeeper.
Deficiency in ability to think, perceive, reason or remember. Results in loss of ability to attend to one's daily living needs.
Provision stating that insured and insurer will share all losses covered by the policy in a previously agreed upon proportion, i.e., 80-20 means the insurer would pay 80% and the insured would pay 20% of all losses. See also Percentage Participation.
Competitive Medical Plan (CMP)
Refers to permission given by the federal government allowing an organization to write a Medicare risk contract.
One rate covering all members of the group regardless of their family status.
Comprehensive Major Medical
Insurance plan that has a low deductible, high maximum benefits, and a coinsurance feature. A combination of basic coverage and major medical coverage that has replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.
Contract providing the insured may renew it to a stated date or an advanced age, that is subject to the right of the insurer to decline renewal only under conditions as previously stated in the contract.
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986
Legislation providing 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 up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may continue up to 36 months in other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.
Terminated employees are allowed to continue their group health insurance coverage under certain conditions.
The period running from effective date to expiration date of contract.
Coordination of Benefits (COB)
Group policy provision that determines the primary carrier in situations when insured is covered by multiple policies. Prevents insured from receiving claims overpayments.
Arrangement where covered person pays a specified amount for specified services and health care provider pays remainder. Covered person usually pays his or her share when service is rendered. Unlike coinsurance which is a percentage, co-payment is a dollar amount.
Often used with major medical policies. Copay provision states percentage of a claim the company will pay and percentage the insured will pay. Example, an 80 percent copay provision the insurer pays 80 percent of claims and the insured pays 20 percent.
Major Medical deductible providing for a deductible, or "corridor," after full payment of basic hospital and medical expenses to a stated amount. If further expenses are incurred, payment is on the basis of participation or coinsurance, such as 80%-20% or 85%-15%, and deductible is portion paid by the insured.
Cost of Living Benefit
Optional disability benefit where monthly benefit is increased annually once insured is on claim for 12 months.
Covered persons pay a portion of the health costs such as deductibles, coinsurance, or copayment amounts.
Health care expenses incurred by covered person that qualify for reimbursement under a policy contract.
Person who pays premiums to the contract for benefits provided and also meets eligibility requirements.
Care primarily for meeting personal needs such as assistance in bathing, dressing, eating or taking medicine. Can be provided by someone without professional medical.