Glossary

Capitation

In some kinds of managed care plans, the health insurer pays physicians that participate in the network a fee called capitation. Generally, this is a fixed, prepaid amount that the provider receives as compensation for all services provided to a plan member.

Case management

A process of identifying individuals who have complex health care needs and coordinating the care they receive in an attempt to improve care outcomes.

Certificate of Coverage (Certificate of Insurance)

A description of the benefits, limitations and exclusions included in a health benefits plan. A copy of the Certificate of Coverage is generally provided when you enroll in a plan. Replacement copies can be obtained by contacting your plan directly, or in many cases through your employer.

Certified Financial Planner (CFP®)

An individual who assists others in financial planning and has met the following qualifications from the Certified Financial Planner Board of Standards, Inc. (CFP Board):

• Successfully completed the CFP Board's certification examination, which tests the individual's knowledge of key financial planning tools
• Acquired three to five years of financial planning-related experience before receiving the CFP certification
• Agreed to the CFP Board's code of ethics
• Agreed to complete 30 hours of financial planning continuing education classes every two years in areas such as estate planning, retirement planning, investment management, tax planning, employee benefits and insurance

Claim

Information submitted to a health plan to request payment for medical services provided to a person covered under that health plan.

Co-insurance

The portion of the cost of covered medical services paid by the patient under a health plan, after first meeting any applicable plan deductible. Co-insurance amounts, which are typically a percentage of the cost, may vary by type of service. Co-insurance requirements are specified in the plan documents.

Co-payment

A set dollar amount or portion that you pay for your medical services. Usually, co-pays start after you first pay any deductible your plan has. Co-pays may differ by type of service. You can find your co-insurance rules in your plan documents.

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986)

A law that permits individuals to continue coverage temporarily under most employer health insurance plans when they would otherwise lose eligibility due to a loss of employment or a change in family status (such as divorce). The cost of this continued coverage is paid by the employee or dependent who elects it. Small employers, those with less than 20 employees, are generally not subject to COBRA.

Coinsurance

The portion of the cost of medical services that you pay for, after you first pay any deductible your plan has. Co-insurance amounts are typically a percentage of the cost. (For example, your health plan may pay 80% and you may pay 20 %.) The percentage may differ by type of service and whether services are provided by providers who participate in Aetna's network. You can find your co-insurance rules in your plan documents.

Consumer-directed health plan

Also referred to as "consumer-driven" or "consumer choice" health plans. A relatively new type of health plan designed to give consumers more control over a portion of their health benefit dollars, typically through a health fund or account that can be used to pay for covered medical expenses. Most health funds allow unused dollars to be rolled over from year to year, for as long as an individual is in the plan, and some plans allow the funds to go with you, even if you change jobs.

Contract Holder

An employer or individual who purchases a health benefits plan from a health insurer.

Conversion Option

An option that allows an individual who is leaving an employee health benefits plan to purchase individual coverage at a pre-determined rate. This is often an option to COBRA continuation. Conversion is only available under certain plans.

Coordination of Benefits (COB)

When an individual is covered under more than one health benefits plan, coverage is "coordinated" to avoid duplicate payments. Rules establish which plan will pay benefits first and allow for sharing of claims information between plans.

Covered Expense/Covered Services

See Allowable Expense(s)

Credentialing

A system for assessing the professional/clinical qualifications and record of a physician, health professional or health facility. This includes a review of relevant training, academic background, experience, licensure, board certification and/or accreditation to provide certain types of medical services. Most health plans credential physicians and facilities before adding them to their list of participating providers and periodically re-credential these providers while they remain in the network.

Custodial Care

Services provided to attend to an individual's daily living activities, which does not require trained medical personnel. Examples include assistance in walking, bathing, dressing, and feeding. Coverage for custodial care is not included in most basic health benefits plans, including Medicare; check your plan documents to see if it is covered under your plan. Custodial services typically ARE covered under long term care insurance, making this a valuable supplement to traditional health coverage.

Customary and Reasonable

Usual, Customary and Reasonable (UCR)