Definitions of Common COBRA Health Insurance Terms
Below you will find a helpful list of common terms used by insurance carriers. Click any of the links below to jump to a definition. COBRA and health insurance can be confusing and overwhelming, especially while also looking for work or dealing with medical conditions. Cobra Help Center guarantees a comprehensive major medical plan when your COBRA expires. If you are going on, currently on or about to lose your COBRA we can help! Click the Contact Us button below to have a underwrite contact you about your situation.
Certificate of Creditable Coverage
Fully Insured Group Health Plan
Pre-existing Condition Exclusion Period
Break in Coverage - A period in which an individual has no Creditable Coverage.Top
Certificate of Creditable Coverage - The Certificate of Creditable Coverage is issued to demonstrate that you have had medical coverage for more than the period required to have Pre Existing conditions not imposed upon you.Top
CHAMPUS - Civilian Health and Medical Program of the Uniformed Services (known since March 1995 as TRICARE).Top
COBRA - Allows for continuation of your prior employer provided healthcare plan when you terminate employment. COBRA requires that if an employee or other “qualified beneficiary” loses employer-provided health coverage due to termination of employment or another specified triggering event, the group health plan must offer continued health care coverage to the qualified beneficiary. The qualified beneficiary may be required to pay the full cost for the coverage plus up to 2% administrative costs. The ‘COBRA Coverage” will have a limited duration. In most cases, the maximum COBRA period is 18 or 36 months depending on the qualifying event.Top
Continuous Coverage - Health insurance coverage that is not interrupted by a significant lapse of time, based on the laws that apply in your state.Top
Creditable Coverage - Health insurance coverage that meets minimum benefit standards.Top
Disclosure Form- Typically refers to the various documents that are provided to applicants to explain benefits or services provided.Top
Election Form - Form used to enroll in the COBRA plan, listing things such as qualifying events, contact information, beneficiaries, start date, end date, as well as all contractual obligations of the carrier and the insured.Top
Elimination Rider - A feature permitted in individual health plans that can or will exclude medical coverage for a specific health condition, body part, or body system. Elimination riders can last indefinitely. Elimination riders are used by insurance carriers to eliminate from the policy's coverage the perceived health risks to reduce or eliminate policy claims.Top
Fully Insured Group Health Plan. - Health insurance purchased by an employer from an insurance company. Fully insured health plans are regulated by state governments.Top
Group Health Plan - A plan sponsored by an employer, union or professional association that covers at least 2 employees and can be insured or self-insured.Top
Guaranteed Issue - A requirement that health plans must permit you to enroll regardless of your health status, age, gender, or other factors that might predict your use of health services. All health plans sold to small employers are guaranteed issue. Plans that are not guaranteed issue can turn you away for other reasons. Virtually all individual health plans, with a few exceptions based on the applicant’s resident state, are health underwritten and NOT guaranteed issue.Top
Health Insurance - Benefits consisting of medical care (provided directly or through insurance or reimbursement) under any hospital or medical service policy, plan contract, or HMO contract offered by a health insurance company or a group health plan. It excludes accident or disability income insurance, workers compensation, automobile insurance with medical coverage, coverage for on-site medical clinics or dental or vision benefits.Top
Individual Health Plan - Private policies purchased by the self-employed, unemployed or people that have no group health insurance for themselves (or their family members).Top
Large Group Health Plan - One with more than 50 eligible employees.Top
Lay-Off - An employment decision where the employer makes the decision not to replace a position and the reduction occurs because of financial considerations. A Lay-Off is not a discharge.Top
Look Back Rule - One of the restrictions of pre-existing Condition Exclusions imposed by health plans to eliminate coverage of medical conditions that existed prior to the policy being issued. Such exclusions are limited to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period prior to the Enrollment Date. It is also considered the maximum length of time immediately prior to enrolling in a health plan that can be examined for evidence of pre-existing conditions. This look back period is often 10 years for most individual plans.Top
Medicaid - A state program providing comprehensive health insurance coverage where eligibility levels and covered benefits vary.Top
Medically Necessary - Services or supplies that are proper and needed for the diagnosis, direct care, or treatment of your medical condition, meet standards of good medical practice, and are not mainly for the convenience of you or your doctor.Top
Medicare - A federal government program that pays for services and supplies it considers "medically necessary".Top
PCE - Pre-existing Condition Exclusion.Top
Plan Administrator - Either the person or entity named as plan administrator in the plan instrument, or, if no one is named, the plan sponsor.Top
Plan Sponsor - The plan sponsor of a single-employer plan is the employer.Top
Pre-existing Condition - Any condition (either physical or mental) for which medical advice, diagnosis, care, or treatment was recommended or received generally within the 6-month period immediately preceding enrollment in a health plan. However, look back periods can apply and therefore the time frame can be as long as 10 years. Group health plans, generally, cannot count pregnancy as a pre-existing condition. Genetic information about your likelihood of developing a disease or condition, without a diagnosis of that disease or condition, cannot be considered a pre-existing condition. Newborns, newly adopted children, and children placed for adoption covered within 30 days cannot be subject to pre-existing condition exclusions.Top
Pre-existing Condition Exclusion Period - The time during which a health plan will not pay for covered care relating to a pre-existing condition.Top
Qualified Beneficiary - Individuals who are allowed to continue coverage based upon certain "qualifying events".Top
Qualifying Event - A loss of coverage under a group health plan on account of one of the specific events described below:Top
- Death of the covered employee
- Voluntary or involuntary termination of the covered employee’s employment (other than by reason of gross misconduct), or reduction of hours of the covered employee’s employment
- Divorce or legal separation of the covered employee from the employee’s spouse
- Covered employee becomes entitled to benefits under Medicare
- Dependent child ceasing to be a dependent child under the generally applicable requirement of the plan; and
- An employer’s bankruptcy (but only with respect to health coverage for retirees and their families).
Small Group Health Plans - Plans with at least 2 but not more than 50 eligible employees.Top
Waiting Period - The time you may be required to work for an employer before you are eligible for health benefits. Not all employers require waiting periods. Waiting periods do not count as gaps in health insurance for purposes of determining whether coverage is continuous. If your employer requires a waiting period, your pre-existing condition exclusion period begins on the first day of the waiting period.Top
