Insurance terms

The Consumer Operated and Oriented Plan program, or CO-OP, is designed to provide nonprofit, member-governed health insurance options.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families to continue their employer-sponsored health insurance coverage temporarily after leaving a job, usually at a higher cost.

With respect to health insurance, a cancellation refers to the termination of the insurance policy or coverage either by the insurance company or the insured person before the end of the period of coverage.

This type of insurance provides financial support if someone is diagnosed with cancer. It helps cover treatment costs, including medical bills, medications, and other related expenses.

This alternative payment model is like a flat-rate subscription for healthcare services. Capitation is a payment method in which healthcare providers receive a fixed amount per patient to cover all necessary medical services. Primary care physicians or integrated hospital-insurer networks will manage total care for a large patient group under an agreed-upon capitated rate paid upfront on a monthly basis by associated health plans. This prepaid lump sum remains the same per member regardless of utilization levels or whether they are healthy versus battling complex diseases. By prepaying for expected care expenses based on large-scale projections, this system incentivizes efficient preventative services over costly acute treatments.

A carrier is another name for an insurance company that offers insurance coverage, manages policies, and pays for covered services.

When prolonged hospitalizations or complex chronic illnesses lead to intensive ongoing care needs, case management helps coordinate treatments with medical teams, health plan administrators, patients, and family caregivers. These patient-centered services aim to optimize recovery outcomes and quality of life while managing the runaway costs of ambulant visits, home therapies, community care referrals, special equipment acquisition, etc. Case managers help enhance continuity and reduce duplication and contradictions across multi-specialist providers.

These are high-deductible health plans designed for young or healthy individuals, offering minimal coverage but protection in cases of severe medical emergencies or accidents.

CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

Proof of a person’s current or most recent insurance policy details will come via this official document, usually provided when coverage ends or changes. It provides evidence that legally entitles you to enroll in another individual or group health plan without exclusions or waiting periods imposed based on preexisting conditions. Certificates list the start and end dates, covered dependents, prior payer contact info, policy numbers, etc.

Think of this as the membership card for an insurance policy. It is a document that confirms your coverage details, such as the type of insurance, coverage period, and benefits included.

CHIP provides low-cost health coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance.

The claim is a request for payment submitted by a healthcare provider to an insurance company for services provided to a patient.

Since health insurance is a contract, it includes clauses. A clause in this context refers to the financial responsibility of the insurance company to the policyholder as stipulated in the contract.

A list of medications (formulary) which may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.

Think of this as cost-sharing in a joint venture. It is the percentage of healthcare costs you share with your insurance company after you have paid your deductible.

In terms of insurance, a commission is a fee in a percentage of the premium that an insurance company pays an insurance agent in exchange for soliciting applications for insurance for the company.

A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors.

A composite rate is an insurance premium based on the average risk profile of a group rather than the risk profile of an individual policyholder. A composite rate implies that all members of a particular group pay the same insurance premium for coverage.

Comprehensive coverage includes a wide range of healthcare services and treatments, offering extensive protection against various health issues.

Coordination of Benefits (COB) refers to the rules that determine the primary plan and the secondary plan when an insured has two or more policies covering the same risks. It prevents insurers from overpaying for claims.

Copayments are fixed amounts paid for specific services covered by insurance, often due at the time of service.

This involves sharing expenses between an insured person and their insurance company, including deductibles, copayments, and coinsurance.

A subsidy for eligible individuals or families to reduce out-of-pocket costs such as deductibles, copayments, and coinsurance. If you qualify, you must enroll in a plan in the Silver category to get the extra savings.

Every policy will list exclusions, or services they don’t cover. Certain prescription meds, alternative treatments, extremely high-cost new therapies, or experimental procedures will almost never be included. Say you want LASIK eye surgery? Most health plans strongly resist covering these vision enhancements as a "non-essential benefit.” Digging through exclusions upfront helps avoid unpleasant surprise bills later.

This term refers to the comprehensive list of medical care, tests, treatments, therapies, and services covered by your health insurance. Everything from preventive scans to complex surgery may fall under this umbrella, as long as it's deemed medically necessary.

Like a safety net for tough times, this insurance policy pays a lump sum or provides a benefit if the insured person is diagnosed with a serious illness such as cancer, stroke, or heart attack.