ACS :: Glossary of Terms

Certificate of creditable coverage: A written certificate issued by a group health plan or health insurance issuer that shows a person's creditable coverage under the plan. A certificate must be issued automatically and free of charge when an individual loses coverage under a plan, when an individual is entitled to elect COBRA continuation coverage, and when an individual loses COBRA continuation coverage. A certificate must also be provided free of charge upon request while the individual has health coverage or within 24 months after their coverage ends. See also Creditable coverage.

COBRA (Consolidated Omnibus Budget Reconciliation Act): COBRA gives a person who loses their health benefits in certain circumstances the right to choose to keep group health benefits provided by their health plan for a limited time. COBRA allows the employee to buy health insurance back from the employer even though the employee no longer works there or no longer works full-time. When COBRA coverage runs out, some people have special eligibility for individual health coverage. See the section "If I can't get group coverage, and have no other options, what do I do?"

Creditable coverage: Health coverage of an individual under a group health plan, (including while on COBRA continuation coverage), individual health insurance coverage, Medicare, Medicaid, a state health benefits risk pool, a public health plan, and certain other health programs. May be used to offset time from any pre-existing condition exclusion if no significant break in coverage (generally 63 days) happened before starting a new group health plan.

ERISA (Employment Retirement Income Security Act of 1974): ERISA is a federal law that oversees employee benefit plans (such as group health plans) that private sector employers, employee organizations (such as unions), or both, offer to their workers and families.

Enrollment date: The first day of coverage or, if there is a waiting period, the first day of the waiting period. For individuals who enroll when first eligible, the enrollment date is often the first day of employment.

Fully insured group health plan: A health insurance plan an employer or union buys from an insurance company, an HMO, or a health care service plan. Benefits, premiums and other aspects of the plan are subject to state regulation. (Compare with self-insured group health plan.)

Genetic information: Information about genes, gene products, and inherited characteristics that may come from the individual or a family member. This includes information about carrier status and information from lab tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories, and direct testing of genes or chromosomes.

Group health plan: An employee benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, to the extent that the plan provides medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

Health insurance issuer: An insurance company, insurance service, or insurance organization (including an HMO), that is required to be licensed to engage in the business of insurance in a state and that is subject to state law that oversees insurance.

Late enrollee: A late enrollee is a person who does not enroll in a plan on the earliest date on which coverage can become effective under the terms of the plan or does not enroll during a special/open enrollment period. Under HIPAA, a late enrollee may be subject to a maximum pre-existing condition exclusion of up to 18 months.

Pre-existing condition exclusion: A limitation or exclusion of health coverage for a condition based on the fact that the condition was present before the first day of coverage.

Self-insured group health plan: Plans established by employers or unions which set aside funds to pay their employees' health claims—i.e., the employer or union is acting as its own insurer. Self-insured plans often hire insurance companies to administer them (for instance, handling enrollment, paying claims, etc.), so they may be mistaken for being the actual insurer. Employers must let health plan enrollees know if an insurance company is responsible for actually insuring them or only for administering the plan. If the insurer is only administering the plan, it is self-insured. The U.S. Departments of Labor and Treasury regulate self-insured plans under ERISA; they are not subject to state law.

Significant break in coverage: As defined by HIPAA, a break in coverage of 63 days or more. May be longer if your state law allows the break in coverage to be longer while still counting the previous creditable coverage time.

SMM: Summary of material modifications or documents that employers are required to provide to employees at certain key intervals to make sure they inform participants and beneficiaries of "material reductions in covered services or benefits" (for example, reductions in benefits or increases in deductibles and co-payments), generally within 60 days of putting the changes into practice.

Waiting period: The period that must pass before an employee or dependent is eligible to be covered under the terms of a group health plan.

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