The 12-month period that begins on January 1 and ends on December 31.
A method of payment for health services in which a medical or dental provider is paid a fixed amount for each person served regardless of the number or nature of services provided to each person, usually associated with a health maintenance organization (HMO) plan or a prepaid dental plan.
This is the maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 to September 30). Point-of-service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
Offered with Medicare Part D, catastrophic coverage is designed to prevent you from having to pay very high out-of-pocket expenses. Once you have spent a pre-determined amount on your prescription drugs within a year, you will pay no more than 5% for each prescription drug. You will still need to pay your monthly premiums for the plan.
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.
A health plan available in the individual market to persons under age 30 and those that have received a hardship exemption certification from the Marketplace. Catastrophic plans cover essential health benefits and pay no benefits until the plan’s annual high deductible is met except for the first three primary care office visits per year.
Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention is an agency of the federal Department of Health and Human Services and is responsible for protecting public health and safety through the control and prevention of disease, injury and disability.
Centers for Medicare & Medicaid Services (CMS)
The federal agency that oversees the Medicare Advantage program, Medicare prescription drug program, Medicaid and the federally-facilitated Marketplace.
Certain Medicare Supplement requirements
To be eligible for a Medicare supplement plan, you must have Medicare Part A and Part B. You have the right to buy a Medicare supplement policy if you are in your Medicare supplement Open Enrollment Period or qualify for guaranteed issue. Your Medicare supplement Open Enrollment Period, for Medicare supplement plans, lasts 6 months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. Once your Medicare supplement Open Enrollment Period starts it cannot be changed. Federal law doesn’t require insurance companies to sell Medicare supplement policies to those under age 65. However, some states may require insurance companies to sell you a Medicare supplement policy, even if you are under age 65. To find out more, check with your state insurance department.
Certificate of Coverage
A description of the benefits included in a benefit insurer's plan, the certificate of coverage is required by state law and explains the coverage provided under the contract. See also Certificate of Insurance, Benefit Plan Document, and Evidence of Coverage.
Certificate of Insurance
This certificate serves as proof of insurance and outlines benefits and provisions.
CHAMPUS Maximum Allowable Charge (CMAC)
A nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
The federal health benefits program for eligible family members of 100% totally and permanently disabled Veterans. CHAMPVA is administered by the Department of Veterans Affairs and is a separate federal program from the Department of Defense TRICARE program. For questions regarding CHAMPVA, call 1-800-733-8387 or email firstname.lastname@example.org.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The healthcare program established to provide purchased health care coverage for ADFMs and retired service members and their family members outside the military’s direct care system. TRICARE Management Activity was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. The purchased care benefits authorized under the CHAMPUS law and regulations are now covered under TRICARE Standard.
A request for payment (also called a bill) for services and benefits you have received.
A unique number assigned by Humana to internally identify a claim.
Where the claim is in the processing stage (pending, paid, denied, in review, etc.).
The type of expense incurred, such as medical, dental or pharmacy.
The process of assessing a claim for accuracy and applicability to the member's coverage before payment is made to the provider or member.
Physicians, therapists, mid-level practitioners, nurses and other medical professionals who provide care to patients in the clinic setting.
Closed panel network
A network of providers from whom all services must be received for coverage to be provided, with the exception of emergency care.
The Consolidated Omnibus Budget Reconciliation Act, or COBRA, is a federal law that requires group health plans for employers with 20 or more employees to offer temporary continued benefits coverage to employees and covered dependents who have had a qualifying event and lost eligibility for coverage. See also Continuation.
After you pay any plan deductibles, you may still be responsible for a percentage of the billed charges for services you received. This is called coinsurance. For instance, if your health plan pays 70% of billed charges, your coinsurance payment is the remaining 30%.
In the drug-screen context, the gathering of a patient’s urine, blood or hair for laboratory testing.
Comprehensive Outpatient Rehabilitation Facility (CORF)
A medical facility that provides outpatient rehabilitation services to the injured and disabled, and to patients recovering from illness. The CORF must provide the following core services: a) physicians’ services, b) physical therapy services, and c) social and/or psychological services.
Continuation refers to a state mandated or federally (COBRA) mandated offer of temporary continued group health plan coverage to employees and covered dependents who have had a qualifying event and lost eligibility for coverage. State continuation varies depending on state law.
A provider who agrees to abide by an insurance company's terms, conditions and reimbursement arrangements. See also in-network provider.
Types of plans including but not limited to health maintenance organization (HMO), traditional, preferred provider organization (PPO) or prepaid/dental HMO (DHMO) selected.
The period of time from the effective date of the contract to the expiration date of the contract.
An employer benefit plan in which employees pay at least part of the premium.
A provision which gives the insured the option to switch from a group policy to an individual policy when the insured is no longer eligible for coverage under the group policy. This varies by state insurance law, contract or plan type.
Coordination of Benefits (COB)
If you have multiple benefits plans, the COB rules determine which plan pays benefits first.
The flat amount you pay to a healthcare provider or pharmacy at the time of service, copayments vary depending on your plan and the services you receive.
Corporate services provider
A class of TRICARE-authorized providers consisting of institutional-based or freestanding corporations and foundations that render professional ambulatory or in-home care and technical diagnostic procedures.
The amount you pay for medical care or prescription drugs. This may include a copayment, coinsurance or deductible.
A coverage gap for Medicare Part D in which you will be responsible for 100% of drug costs as your expenses for prescriptions exceed a certain amount but don’t yet meet the catastrophic coverage threshold.
Under HIPAA, a health plan, a healthcare clearinghouse or a healthcare provider who transmits any health information in electronic form in connection with a HIPAA transaction.
Qualifying costs that you incur and which your plan may pay or reimburse you for in accordance with the terms of your policy.
An individual who meets a health plan's eligibility requirements and for whom the required premium has been paid for coverage.
The process of approving a provider to participate in a plan’s provider network.
The process by which providers are allowed to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.
Creditable coverage (Medicare prescription drug plans)
Prescription drug coverage (such as plans offered by an employer or union) that covers as much or more than Medicare’s standard prescription drug plan.
Creditable coverage (Medicare supplement plans)
Any sort of health insurance plan that you are eligible to use which can shorten the pre-existing condition/long waiting period that is part of your Medicare supplement policy.