- Cafeteria Plan
A cafeteria plan is a flexible benefits plan that meets the requirements of IRC Section 125 and offers eligible employees a choice between cash salary and a variety of nontaxable benefits (e.g., health insurance), known as qualified benefits. Employees are allowed to pay for the benefits they choose on a pre-tax basis.
- Related Terms: Flexible Benefits Plan, Flexible Spending Arrangement, Internal Revenue Code, Premium Only Plan, Qualified Benefits
A carrier is the insurance company responsible for claims processing. A carrier may also be the stop-loss insurer for a self-funded plan that agrees to underwrite (i.e., carry the risk) and provide excess-loss coverage and service.
- Related Terms: Self-Funding, Stop-Loss Coverage, Third-Party Administrator
- The term "CDHC" means consumer-driven health care.
- Related Terms: Consumer-Driven Health Care
- Change in Status
A change in status refers to an event that modifies the employee's legal marital status, the number of the employee's dependents, the employment status of an employee or one of the employee's dependents, the place of residence of an employee or one of the employee's dependents, or the eligibility status of a dependent for coverage under a plan.
- Related Terms: Dependent, Eligibility, Enrollment
- A claim is a request made of a plan for payment of medical services rendered.
- Related Terms: Claim Adjudication, Fee for Service
- Claim Adjudication
Claim adjudication refers to the review and processing of a claim based on eligibility, fee schedules, usual and customary amounts, and benefit coverage.
- Related Terms: Claim, Claim Lag, Usual and Customary
- Claim Administrator
A claim administrator is the person or firm, if any, that a plan administrator retains to handle the processing, payment, and settlement of benefit claims and other duties that are specified in a written administration agreement. If there is no claim administrator (for any reason, including the termination or expiration of the administration agreement with the initial claim administrator), or if the term is used in connection with a duty not expressly assumed by the claim administrator in signed writing, the term means the plan administrator.
- Related Terms: Plan Administrator, Third-Party Administrator
- Claim Lag
Claim lag refers to the time interval between the date a service is rendered or an item is supplied and the date a service or item is processed and paid.
- Related Terms: Claim, Claim Adjudication
- The term "COB" means coordination of benefits.
- Related Terms: Coordination of Benefits
- The term "COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985.
- Related Terms: Consolidated Omnibus Budget Reconciliation Act of 1985
Co-insurance is the amount that a covered person must pay for covered health care during a benefit year after meeting the deductible.
- Related Terms: Benefit Year, Deductible
- Collectively Bargained Plan
A collectively bargained plan is an employee benefits plan that is negotiated between a union and an employer.
- Related Terms: Employee Benefits Plan, Employee Welfare Benefits Plan
- Consolidated Omnibus Budget Reconciliation Act of 1985 — COBRA
COBRA is federal legislation that requires employers who maintain 20 or more employees (including part-time employees who are counted as fractions of full-time employees) during at least 50 percent of the business days in a calendar year to offer extended group health coverage to certain classes of employees and dependents when specific qualifying events occur (e.g., termination of employment, reduction in number of hours of employment, or the divorce or death of the covered employee). Coverage generally may last for up to 18 months for employees and up to 36 months for dependents.
- Related Terms: Mandated Benefits, Omnibus Budget Reconciliation Act, Qualified Beneficiary, Qualifying Event, Uniformed Services Employment and Reemployment Rights Act of 1994
- Consumer-Driven Health Care — CDHC
CDHC is an arrangement that is intended to encourage cost-conscious use of health care by giving individuals a financial stake in reducing their health care costs (e.g., by increasing insurance deductibles or by providing access to a medical savings/reimbursement account).
- Related Terms: Cost Containment, Managed Care
- Coordination of Benefits — COB
COB is a cost-savings feature that applies when a participant is covered by multiple plans. In this situation, one plan normally pays its benefits in full and the other plan(s) pays a reduced benefit. COB guarantees that the total paid by all plans will not exceed 100 percent of the billed charges.
- Related Terms: Primary Plan, Secondary Plan
A co-payment is a cost-sharing arrangement under a health plan in which a participant pays a specified dollar amount for a service, such as $10 for a prescription or $20 for a doctor's office visit. Co-payments are generally not included in the out-of-pocket maximum.
- Related Terms: Co-Insurance, Out-of-Pocket Maximum
- Cost Containment
Cost containment refers to activities such as pre-certification, case management, mandatory second surgical opinions, and benefit incentives, all of which aim to reduce the cost of medical care or limit its rate of increase.
- Related Terms: Managed Care, Utilization Review
- Covered Entity
A covered entity includes health plans, health care clearinghouses, health care providers, and endorsed sponsors of the Medicare prescription drug discount care that conduct covered transactions electronically. Covered entities are subject to HIPAA's Administrative Simplification mandates.
- Related Terms: Business Associate, Health Insurance Portability and Accountability Act of 1996, Protected Health Information
- Covered Expenses
Covered expenses are charges a covered person incurs for any medically necessary treatments, services, or supplies that the plan does not specifically exclude from coverage. A covered person incurs covered expenses on the date that he or she receives any medically necessary treatments, services, or supplies.
- Related Terms: Benefit, Medically Necessary
- CPT Code
- A CPT code is a current procedural terminology code.
- Related Terms: Current Procedural Terminology Code
- Creditable Coverage
Creditable coverage is coverage of an individual under a group health plan, a group or individual health insurance policy, a health maintenance organization (HMO), Medicare, Medicaid, the State Children's Health Insurance Program (S-CHIP), a public health plan, or any other health plan as set forth in Section 401 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended, and federal regulations issued pursuant to HIPAA.
- Related Terms: Health Insurance Portability and Accountability Act of 1996, Health Maintenance Organization
- Current Procedural Terminology Code — CPT Code
A CPT code is a five-character, alpha-numeric code that providers use to bill a specific service to an individual or plan. The American Medical Association maintains CPT codes.
A custodian is an organization such as a bank, brokerage firm, or mutual fund company that holds the cash and securities of a 401(k), IRA, health savings account, or mutual fund and performs a variety of clerical services (e.g., collecting income and reporting on the value of the assets).
- Related Terms: Fiduciary, Trustee