Glossary of Terms

Term

Care Coordination

The organization of your treatment across several health care providers. Medical homes and Accountable Care Organizations are two common ways to coordinate care.

Term

Carrier

A health insurance plan or organization.

Term

Catastrophic Health Plan

A catastrophic health plan meets all the requirements of other Qualified Health Plans (QHPs), but does not cover any benefits other than 3 primary care visits per year before the plan’s deductible is met. Catastrophic health plans have lower monthly premiums but higher deductibles, co-payments, and co-insurance. You cannot use a…

Term

Certified Application Counselor

Similar to a Navigator, a Certified Application Counselor is an individual who is trained to help individuals and families apply for and enroll in coverage through the online application in Washington Healthplanfinder. These Counselors usually work in a hospital or other medical setting. Their role is to help people who…

Term

Children’s Health Insurance Program (CHIP)

A low-premium insurance program jointly funded by the state and federal government that provides health coverage to low-income children. In Washington State, CHIP is known as Children’s Washington Apple Health.

Term

Chronic Disease Management

An integrated care approach to managing illness that includes screenings, check-ups, monitoring and coordinating treatment, and patient education. If you have a chronic disease, it can improve your quality of life and reduce your health care costs by preventing or minimizing the effects of that disease.

Term

Claim

A request for payment that you or your health care provider submits to your health insurer when you get health care items or services you think are covered.

Term

Co-Insurance

Your share of the costs of a covered health service. You start to pay co-insurance after you have paid your health plan’s deductible. Your plan pays the rest. Some health plan’s pharmacy benefits are set up so you pay co-insurance instead of a co-pay until your deductible is met.

Term

Co-Pay or Co-Payment

A fixed amount that you pay for a covered health care service, such as a regular doctor’s visit or prescription. Co-pays are paid at the time of service and do not apply toward your deductible costs.

Term

COBRA

A federal law that may allow you to temporarily keep health coverage in some situations: 1) after your employment ends; 2) if you lose coverage as a dependent of the covered employee; or 3) another qualifying event. If you elect COBRA coverage, you pay 100% of the premiums, including the…

Term

Community Rating

A method of setting premiums so that risk is spread evenly across the community, with all individuals in a community paying the same premium rate regardless of their health status and other factors such as age, gender, and other characteristics. A variation of community rating is adjusted community rating where…

Term

Complication of Pregnancy

Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the baby. Maternity and newborn care for women who have complications of pregnancy are now Essential Health Benefits. Morning sickness and non-emergency cesarean sections are not covered as…

Term

Conditional Eligibility

If you submit an application through Washington Healthplanfinder without necessary documentation, and you are otherwise eligible, you will be determined conditionally eligible. You have 90 days from submission to provide the required documentation.

Term

Coordination of Benefits

The process used to decide which plan pays first when 2 or more plans cover the same individual and are both responsible to pay for a portion of a claim.

Term

Cost Sharing

The share of costs for care covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, co-insurance, and co-payments, or similar charges. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. In Washington Apple, cost…

Term

Cost-Sharing Reduction

Cost-sharing reductions are a discount that lowers the amount you pay for deductibles, co-insurance, and co-payments and other out-of-pocket expenses (like lab tests and drugs). There have been some federal conversations about changing these discounts. More information is available at www.wahbexchange.org/staycovered. You can get this reduction if you: Get…