COBRA Participant: a qualified beneficiary who elects to continue coverage under the Plan due to a qualifying event.
Coinsurance: the amount of an allowable charge (usually a percentage) that a participant pays for covered expenses after the appropriate deductible is met.
Coinsurance Maximum: the amount indicated in the Select Coverage Summary of Benefits in unreimbursed expenses for covered expenses a participant incurs in a calendar year, after which benefits are paid at 100% of the allowable charge for the remainder of the calendar year. Certain expenses cannot be used to the meet the coinsurance maximum.
Coinsurance/Co-payment Maximum: the amount indicated in the Base Coverage Summary of Benefits in unreimbursed expenses for covered expenses a participant incurs in a calendar year, after which benefits are paid at 100% of the allowable charge for the remainder of the calendar year. Certain expenses cannot be used to the meet the coinsurance/co-payment maximum.
Convalescent Facility: An institution (or distinct part thereof), which meets each of the following tests:
It is primarily engaged in and licensed to provide, for compensation, “skilled nursing services or intermediate care services” and “physical restoration services” to convalescing patients on an inpatient basis. It provides these services on a twenty-four (24) hour daily basis and under the full-time supervision of a physician or a registered nurse, with licensed nursing personnel on duty at all times. It maintains a complete medical record on each patient and has a utilization review plan for all of its patients. It is not, other than incidentally, a place for rest, “custodial care,” educational care, the care of mental disorders, or a place for the aged. Mental disorders include, but are not limited to, drug addiction, alcoholism, chronic brain syndrome, and mental retardation.
“Skilled nursing services and intermediate care services” means services rendered by a registered nurse or by a licensed practical nurse under the direction of a registered nurse; “physical restoration services means services which assist the patient to achieve a sufficient degree of body functioning to permit self-care in the essential activities of daily living; “custodial
care” means care primarily to aid the patient with of daily living; and, “chronic brain syndrome” involving some irreversible brain damage due to a
bathing, dressing, eating, and other activities means a condition of mental deterioration variety of causes ranging from alcohol abuse
to senile dementia of unknown cause.
Coordination of Benefits (COB): the process that determines the order of benefits payable when an enrollee and/or his eligible dependent(s) are covered under more than one insurance plan.
Co-payment: the amount of an allowable charge (usually a flat fee) that a participant pays for a covered expense after the appropriate deductible is met.