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Cafeteria Plan: A cafeteria plan provides a choice between various qualified benefits or between cash and one or multiple qualified benefits. The plan must comply with Section 125 of the Internal Revenue Code.
Calendar Year: A calendar year refers to the time between January 1 and December 31st of the same given year. A calendar year is frequently used in reference to deductible amounts and out-of-pocket amounts for medical plants that offer benefits for expenses associated with the calendar year.
Capitation: Also known a cap, capitation is a stipulated dollar amount that reflects the cost of healthcare coverage for an individual. Capitation may also refer to a negotiated per capita rate that is prepaid to the healthcare provider. Usually, it is associated with an upper limit on risk assumed by the provider. The provider, according to contract, is tasked to deliver or arrange healthcare for the covered individual in accordance with the carrier's contract.
Carrier: An agency that might underwrite, administer, or sell health insurance benefit programs. It can also refer to a managed healthcare plan or insurer.
Carrier Replacement (CR): Carrier replacement refers to those times when a sole carrier replaces one or several other carriers for a single employer group. Carrier replacement consolidates the group's experience and risk level.
Carve Out: Refers to the separate purchase of an additional benefit. For instance, an HMO plan may carve out mental health benefits and task a special vendor to offer services as a separate option.
Case Management: Refers to medical management of patients and their individual healthcare needs. Case management plans require physicians to help determine a patient's care needs and their coordinated treatment plans that make use of available healthcare resources.
Case Manager: A case manager is typically physician, nurse or social worker to works with patients, insurers, and healthcare providers to determine an appropriate healthcare plan. Sometimes the case manager will be referred to as a care coordinator.
Case Mix: Refers to the type and intensity of hospital admissions as well as the services required to treat different needs. Case mix may be measured in accordance with diagnoses, use of services, and hospital characteristics.
CDPHP: The CDPHP practitioner network features more than 10,000 practitioners and is an award-winning health-benefits provider. It serves a diverse array of communities with its government-sponsored and commercial benefits plans. The CDPHP offers three lines of products: . Capital District Physicians' Health Plan, Inc. . CDPHP Universal Benefits,® Inc. (CDPHP UBI) . Capital District Physicians' Healthcare Network, Inc. (CDPHN)
Centers of Excellence: Network of licensed / certified healthcare facilities based on rigid criteria associated with efficiency and outcomes. As an example, an organ transplant program might require members to access its transplant services via this type of network.
Certificate of Authority (COA): A certificate that is issued by a state government for licensing a health maintenance organization.
Certificate of Coverage (COC): A certificate of coverage provides a description of benefits provided by a carrier's insurance plan. State laws require this certificate of coverage to be provided in associated with the employer-issued contract. This certificate is then presented to the employee. It is often referred to as the "member certificate."
Certificate of Need (CON): Issued by a government agency or body to an organization or individual, the certificate of need is a proposition to construct or alter a healthcare facility. It may also be issued for the acquisition of medical equipment or to offer new types of healthcare services.
Chemical Dependency: Scroll to Substance Abuse.
Chemical Equivalents: Sometimes referred to as referred to as biotherapeutic or therapeutic equivalent, chemical equivalents are multi-source drug products that contain the same amounts of active ingredients (in the same dose) and meet both physical and chemical standards.
Claim: The information that a provider or covered person submits for reimbursement of health service costs.
Closed Panel: This type of benefit plan allows coverage for services performed by contracted healthcare providers. These plan-contracted practitioners may coordinate care or provide referrals for patients. Under some circumstances (i.e. an emergency room visit), a closed panel plan may cover services provided by non-network healthcare providers.
Cognitive Impairment: Refers to memory or reasoning impairment. A cognitively impaired person may require supervision to protect against doing harm to themself or others.
Coinsurance: Refers to a portion of healthcare costs that an insured individual is responsible for paying and is usually attached to a fixed percentage. Coinsurance is usually applied once the deductible has been met or exceeded and in association with an out-of-pocket maximum.
Commercial Products: Health plans that provide health coverage to consumer groups who either pay premiums or their employers pay premiums.
Commission: Compensation paid to a broker, insurance agent, or sales rep for services provided.
Community Rating: A method used to determine premium structures. The structure is influenced by the benefit utilization of a defined group or by the population of a group in its entirety.
Community Rating by Class (CRC): Also termed factored rating, community rating by class refers to the practice of rating a community in accordance with a group's specific traits or demographics.
Competitive Medical Plan (CMP): Refers to government-granted status for meeting specified criteria that enable the organization to have a Medicare risk contract. Under the Balanced Budget Act of 1997, the CMP is no longer applicable.
Complaint Procedure: Scroll to Grievance
Composite Rate: The group billing rates that all group subscribers must pay regardless of family or sing coverage.
Comprehensive Major Medical: This type of medical insurance provides benefits for a broad range of illnesses and injuries.
Concurrent Drug Evaluation: Electronic evaluation of prescription drug claims performed at the point of service in order to detect issues that should be addressed before drugs are dispensed to patients.
Concurrent Review: Evaluation of ongoing services provided to an individual. The review is performed by medical management in accordance with the patient's benefit plan and clinical review guidelines.
Confinement: Refers to an uninterrupted inpatient stay in a hospital, nursing facility, or an approved type of healthcare facility.
Consolidated Omnibus Budget Reconciliation Act (COBRA): The federal law that requires employer to offer a continuance of health insurance coverage to employees and beneficiaries after their group health insurance has been stopped. The law applies to employers who have 20 or more eligible employees. The continued coverage must be offered for a period of 18 or 36 months. Individuals enrolled in COBRA may have to pay 100% of their health insurance premium along with an extra 2%. COBRA gives employees who lose their health insurance benefits the right to continue their group benefits for a limited period of time--typically to accommodate the transition period between jobs, divorce, or other life events. COBRA provides outlines with options for employees and their families for continuation of their coverage.
Consumer Price Index (CPI): Refers to the average change in prices that consumers pay for fixed market goods and services. The Federal Bureau of Labor Statistics reports the CPI on a monthly basis. CPI's medical component will include information pertaining to hospitals, nursing homes, prescriptions, medical supplies, and certified healthcare services.
Contact Capitation: Refers to a method for reimbursement to pay specialist healthcare providers. Typically, payment is made to the specialist at the first point of contact with insured but will cover all services offered by the specialist for a prescribed time period.
Continuation: Occurs when an insured individual is allowed to continue their coverage for a prescribed period of time after they might otherwise have lost benefits due to termination or divorce.
Continuum of Care: The clinical services offered to an individual or group. These treatments might reflect single hospitalization or medical care provided to treat multiple conditions over the course of a lifetime. The continuum provides a framework for assessing the quality of care, its cost, and the utilization of care over a long-term spectrum.
Contract Year: The contract year refers to a 12-month period that begins on the effective date and ends at the end of the 12-month period or the renewal date of the contract.
Contributory Program: Group coverage payment method where part of the premium is contributed by the employer or union and part is paid by the employee who is covered.
Conversion: Refers to when a covered individual changes their group medical coverage without any evidence of insurability. The master group determines the conditions by which conversion can be made.
Coordination of Benefits (COB): Refers to a contract provision that is applied to individuals who are covered by one or more group medical programs. COB ensures that payments of benefits will be coordinated so they do not duplicate benefits.
Copayment: A fee that the insured pays as a cost-sharing arrangement with their insurance provider. Typically, this fee is paid when medical services are rendered. Most copayments are fixed, particularly when it comes to doctor's office visits or prescriptions for medication.
Cosmetic Procedure: Any procedure that involves an individual's physical appearance but does not correct a physiological function.
Cost Containment: Activities designed to reduce medical care costs.
Cost Drivers: Refers to business expense categories that are associated with a considerable percentage of medical costs.
Cost-Effectiveness: Refers to the degree by which a medical service meets the criteria for acceptable cost.
Cost Sharing: Refers to the financial arrangements associated with an insured individual and what they must pay out of pocket for medical care. Aspects of cost sharing are deductibles, copayments, and co-insurance costs.
Coverage: Refers to the various selected options and benefits that are paid for under a health insurance plan.
Coverage Expense: Refers to an expense that will eventually be reimbursed in accordance with the insurance plan.
Covered Person: Refers to the individual who is covered by an insurance plan. This person will meet eligibility requirements and will have made premium payments for healthcare coverage. Some insurers refer to a covered person as a member or plan participant.
CPT: Scroll to Physician's Current Procedural Terminology.
Credentialing: Occurs when a provider applicant is assessed for eligibility to participate in a health plan.
Custodial Care: Non-curative medical and non-medical services that are offered to patients even when their condition remains unchanged.