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Individual & Family Health Insurance
Medicare Supplements
Dental Insurance
Small Business Health Insurance
Welcome to Healthinz.com

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CAPITATION: Capitation represents a fixed monthly dollar amount that a Health Maintenance Organization (HMO) pays to a group of health care providers who have contracted with the HMO. The amount of this fixed dollar amount depends upon the number of HMO enrollees who have chosen this group of health care providers for “primary care” services under the HMO plan. This fixed dollar amount does not vary with how much HMO enrollees use (or don’t use) services offered by this group of HMO providers. Not all HMO utilize capitation payments.

CARE PLAN:
A written plan for one’s health care.

CASE MANAGEMENT:
A process whereby an insured person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner.

CASE MANAGER:
A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.

CATASTROPHIC ILLNESS:
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.

CENTERS OF EXCELLENCE:
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants.

CERTIFICATE OF COVERAGE:
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.

CLAIM:
Form submitted to a payer (by a health care provider or patient) to request payment for items or services.

CO-INSURANCE:
Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may apply after a $500 deductible has been satisfied.

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA):
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer durations of continuance are available under certain circumstances. If a former employee opts to continue coverage under COBRA, the former employee must pay the entire premium, plus a 2% administration charge.

CONTRACT YEAR:
The period of time from the effective date of the contract to the expiration date of the contract. A contract year is typically 12 months long, but not necessarily from January 1 through December 31.

COORDINATION OF BENEFITS (COB):
A provision in the contract that applies when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits.

CO-PAYMENT (CO-PAY):
Co-payment is a predetermined fee, in addition to what health insurance covers, that an individual pays for health care services. For example, a PPO may require a $20 “co-payment” for normal services delivered during a physician office visit.

COST SHARING:
This occurs when the users of a health care plan share in the cost of medical care. Deductibles, coinsurance, and co-payments are examples of cost sharing.

COVERED BENEFIT:
A health service or item that is included in a health plan, and that is partially or fully paid by the health plan.

COVERED CHARGES/EXPENSES:
Most insurance plans, whether they are PPOs or HMOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures for which the insurer agrees to pay. They are listed in the policy.

COVERED PERSON:
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.