Human Resources Administration-Office of Citywide Health Insurance Access311Search all NYC.gov websites
Insurance A-Z
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1099 Workers
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
A
Actuarial Value
Actuarial value is the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, the consumer would be responsible for, on average, 30% of the costs of all covered benefits.
Affordable Care Act (ACA)
The health care reform law enacted under President Obama in March 2010. The ACA aims to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of health care for individuals and the government. It provides a number of mechanisms—including mandates, subsidies, and insurance exchanges—to increase coverage and affordability.
Appeal
A request for your health insurer or plan to review a decision to deny payment for health care services that they have initially determined to be not medically necessary, experimental, or, in certain cases, out-of-network.
B
Benefit
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Brand Name Drug
A prescription drug that received a patent on its chemical entity, formulation, or use and has been approved by the Food and Drug Administration after clinical testing. When patents expire, generic versions of brand name drugs may be offered under a different name and often at lower costs.
Broker
A licensed professional who helps businesses and individuals select and purchase a health plan. Those brokers that choose to sell products in the Marketplace are trained and certified by the NY State Department of Health to complete applications on NY State of Health and receive commission-based compensation. Due to their commission-based compensation, these entities may be biased as to the products they sell since they are paid directly from the insurers. Brokers can choose to certify in the Small Business Marketplace, Individual, or both.
C
Cafeteria Plan
Cafeteria plans, also known as Section 125 plans, allow employees to choose between receiving cash (in the form of earnings) and paying for health insurance and other qualified benefits with pre-tax earnings. For example, one type of Section 125 plan, a premium-only-plan (POP), allows employees to pay for health insurance before taxes, which lowers the amount of the employee's salary subject to federal, state and local income taxes. Section 125 plans also lower the employer's payroll taxes (FICA or Social Security and Medicare taxes).
Carrier
A company or organization that offers health insurance plans.
Catastrophic Health Plan
Under the Affordable Care Act, a health plan geared towards people under 30 and some people with limited incomes. It meets all the requirements applicable to other Qualified Health Plans (QHPs) in the Marketplace but does not cover any benefits other than 3 primary care visits per year before the plan's deductible is met.
Certified Application Counselor (CAC)
Individuals that are trained and certified by the NY State Department of Health to conduct community outreach and complete applications in the NY Sate of Health Marketplace. Unlike navigators, they do not receive compensation from the state, but rather directly from the entity in which they are employed, which may lead to a conflict of interest when it comes to being unbiased about the plan options offered to potential clients.
Child Health Plus (CHP)
A public health insurance program for children under the age of 19, regardless of their immigration status, that covers a wide range of children's health care and dental needs. Based upon family income, children may qualify for free or low-cost health insurance through this program.
Chiropractic Care
A type of care where the spine is manipulated to relieve pressure on nerves, muscle spasms of the back and neck, tension headaches, and some types of leg pain.
Claim
The bill you or your provider sends to the health plan for health care services that you received.
Co-payment (Co-pay)
A fixed dollar amount paid by an individual at the time of receiving a covered health care service from a participating provider. The required fee varies by the service provided and by the health plan.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
A federal law that allows you to continue health insurance coverage offered by your previous employer usually for up to 18 months after leaving a job. With COBRA coverage, you must pay the full cost of your health coverage and you may be charged a small administrative cost.
Coinsurance
The portion or percent of health care costs that you're required to pay. For example, the health insurer or plan may cover 80% of charges for a covered hospitalization, leaving you responsible for the other 20%. This 20% is known as the co-insurance.
Consumer Operated and Oriented Plans (Co-Op)
A non-profit, member-run health insurance organization that provides insurance coverage to individuals and small businesses through health insurance exchanges and can operate at state, regional, and national levels.
Cost-Sharing
The amount the patient pays for covered health care. Depending on the plan, cost-sharing could include deductibles, co-payments or coinsurance. This does not include premiums or the cost of non-covered or out-of-network services.
Covered Benefit
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
D
Deductible
The amount you must pay for covered health care services, before your health plan begins to pay. You typically must pay a deductible each year. There may be separate deductibles for different types of services, and many plans have no deductible.
Dependent
A person covered under a private health plan who is not primary enrollee or policyholder, usually a spouse or child. In New York State, many plans offered by employers also cover domestic partners.
Diagnostic Exams and Lab Fees
The fees that you pay for laboratory tests (such as blood work and urine tests) and imaging tests (such as x-ray, ultrasound, CT scan, and MRI).
Domestic Partners
A legal relationship permitted under the laws of the State and City of New York for couples that have a close and committed personal relationship. The Domestic Partnership Law recognizes the diversity of family configurations, including lesbian, gay, and other non-traditional couples.
Drug Coverage
Refer to Prescription (Rx) Drug
Drug Maximum per Calendar Year
The total annual amount that a health plan will pay for your prescription (Rx) drugs for the year. If the total cost of your prescriptions is more than the drug maximum in the year, you will have to pay the additional cost. Many plans do not have a drug maximum.
Durable Medical Equipment (DME)
Equipment used in the course of treatment or home care, including items such as crutches, knee braces, wheelchairs, hospital beds and prostheses.
E
Effective Date
The date on which insurance benefits begin.
Emergency
An injury, symptom, or illness that requires immediate medical attention.
Emergency Care
Care for a sudden medical or behavioral condition that a prudent layperson could reasonably expect to result in placing the person's health in serious jeopardy or causing serious bodily or mental dysfunction or damage.
Emergency Room or Emergency Department
The area in a hospital or clinic staffed and equipped to provide emergency care to persons requiring immediate medical treatment.
Employee
A person who is hired for a wage, salary, or other payment to perform work for an employer. An employee generally receives a W-2 statement from his or her employer. An employee can work on a full-time (usually 35 or more hours a week) or part-time (less than the standard hours for full-time work) basis.
Employer Health Care Tax Credit
An incentive designed by the ACA to encourage employers, usually small employers with fewer than 25 employees, to offer health insurance to their employees. The tax credit enables employers to deduct an amount, usually a percentage of the contribution they make toward their employees' premiums, from the federal taxes they owe. These tax credits are typically refundable so they are available to non-profit organizations that do not pay federal taxes.
Employer Mandate
Businesses with 50 or more full-time (or full-time equivalent) employees that don't offer insurance, or offer coverage that doesn't meet certain minimum standards, may be subject to a fee. Learn more about the Employer Shared Responsibility Payment from the IRS.
Refer to Health Insurance Mandate
EPO (Exclusive Provider Organization)
A type of managed care plan, EPOs typically require you to receive care from in-network providers. You do not need a referral from a primary care physician to see a specialist. Out-of-network care is generally not covered.
Essential Health Benefits
A package of benefits set by the Secretary of Health and Human Services and defined by the State of New York that individual and small group market insurers will be required to offer under the Affordable Care Act starting in 2014
Essential Plan
Free or very low cost insurance for adults with low income who don't qualify for Medicaid.
Exemptions
You may be exempt from the requirement to obtain health insurance and will not have to pay the fee when you file your federal income tax return. Find an exemption that may apply to you.Exclusions/Limitations
refers to anything an insurance company will not cover, ranging from a type of drug to a type of surgery. Exclusions can vary from plan to plan.
Explanation of Benefits (EOB)
A summary of a medical care claim. The EOB shows the service rendered; the provider's charge, the insurer's negotiated or allowable charge, how much the insurance company has paid and any balance you must pay. It also includes an explanation of any denial, reduction, or other reason for not providing full reimbursement for the amount claimed; and information on how to file an appeal.
F
Family Planning Benefit Program (FPBP)
The Family Planning Benefit Program (FPBP) is a free and completely confidential New York State program that provides family planning services to teens, women, and men who meet certain income and residency requirements, and who are not enrolled in Medicaid or Family Health Plus.
Federal Poverty Level (FPL)
The set minimum amount of gross income that a family needs for food, clothing, transportation, shelter, and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Medicaid and other programs in the U.S. define eligibility income limits as some percentage of FPL.
Financially Interdependent
The individuals in a domestic partnership are jointly responsible for the financial obligations of the partnership. Insurance carriers may require domestic partners, as an eligibility requirement for coverage, to demonstrate that they are financially interdependent through the submission of documents including but not limited to: a joint mortgage or lease for their place of residence, an agreement for a joint bank or credit account, and mutual grants of power of attorney. Each insurance carrier sets its own documentation requirements.
Flexible Spending Account (FSA)
A type of cafeteria plan (Section 125 Plan) that allows employees to pay for qualified benefits with pre-tax earnings. Qualified benefits include dependant care assistance, adoption assistance, and qualified medical care reimbursements.
Formulary
A list of both generic and brand name drugs that are preferred by your health plan. Your plan may charge you more for drugs that are not included on the formulary (non-formulary drugs) or limit your choices to drugs on the formulary.
Freelancer
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
G
Gatekeeper
Some plans require you to select a primary care physician (PCP) who provides you with basic medical services, coordinates medical care, and refers you to specialists.
Generic Drug
A drug that is similar to a brand name drug. Generic drugs are approved by the Food and Drug Administration if they contain the same active ingredients and have comparable therapeutic effectiveness to a brand name drug. Generic drugs are developed after the patent on a brand name drug has expired and are usually less expensive than brand name drugs.
Grandfathered Plans
Grandfathered plans are those that were in existence on March 23, 2010, and have stayed basically the same. But they can enroll people after that date and still maintain their grandfathered status. In other words, even if you joined a grandfathered plan after March 23, 2010, the plan may still be grandfathered. The status depends on when the plan was created, not when you joined it.
Group Insurance
Health coverage available to individuals based on their affiliation with an employer.
Guarantee Issue/Renewal
Requires insurers to offer and renew coverage, without regard to health status, use of services, or pre-existing conditions.
H
Health Care
Health care is the services you receive from a doctor or another provider to stay healthy or to treat an illness or injury.
Health Insurance
Health insurance is a way to pay for health care. You pay a monthly fee, or premium, to an insurance company. In return, they pay a portion of your health care costs.
Health Insurance Mandate
The Affordable Care Act health care law requires you and everyone in your family, including children, to have qualifying health insurance (known as minimum essential (MEC) coverage) in each month of the year. If you don't have a health plan that qualifies as minimum essential coverage, you may have to pay a fee for the months without coverage (The fee is also called the "fine" or "penalty." For 2016 the penalty is the higher of these two amounts: 2.5% of your household income; or $695 per adult ($347.50 per child), up to a maximum of $2,085. You'll pay the penalty on your federal income tax return. People with very low incomes and others may be eligible for exemptionsHealth Insurance Policy
The terms, conditions, benefits, and obligations of your health plan.
Health Savings Account (HSA)
A financial account established by an employer or an individual that can be used to pay for qualified medical expenses on a tax-free basis. You must be covered by a high deductible health plan (HDHP) that meets certain requirements set by the federal government to establish and contribute to an HSA, and you cannot have other health coverage or be eligible for Medicare.
Healthy New York (HNY) Program
A NYS subsidized health insurance plan that provides comprehensive and lower-cost health insurance coverage to individuals, sole proprietors, and small businesses that meet the program's eligibility requirements. Please note: Healthy NY coverage for Individuals and Sole Proprietors will terminate December 31, 2013.
High Deductible Health Plan (HDHP)
A health plan that requires you to pay more out-of-pocket for services before the health plan starts paying. For individuals to open a health savings account (HSA), they must be enrolled in a HDHP that meets certain requirements set by the federal government, including requirements on the deductible and annual out-of-pocket costs.
HMO (Health Maintenance Organization)
A type of managed care plan that typically requires you to receive care from in-network providers. Some plans require that you obtain a referral from your primary care physician before you can see a specialist. Out-of-network care is generally not covered.
Home Health Care
Health care or supportive care provided in the patient's home usually by healthcare professionals.
Hospice Care
Care provided to people in the final phase of a terminal illness that focuses on comfort and quality of life, rather than cure.
Hospital Inpatient Care
Care that requires a stay in a hospital, usually overnight.
Hospital Outpatient Care
Care that does not require an overnight stay in a hospital and is often provided in a hospital outpatient clinic.
Hospital Stay
The length of time from admission into a hospital until discharge.
I
In-network
Doctors, hospitals, pharmacies, and other health care practitioners that have agreed to provide members of a health plan with services and supplies at a discounted price. Under some health plans, your care is covered only if you receive it from in-network providers.In-Person Assistors
Individuals or organizations that are trained and certified by the State of New York to provide help to consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers. These entities include Navigators, Brokers, and Certified Application Counselors.
Individual/Direct Pay Health Insurance
Coverage that you purchase on your own and not as part of a group or through your employment. Also referred to as direct pay health insurance.
Individual Mandate
A requirement under the Affordable Care Act that all individuals who do not have health insurance coverage must obtain coverage by January 1, 2014, or pay a penalty, unless they can and do claim an exemption.
Individual Insurance Marketplace
The place where individuals and sole proprietors who do not have adequate health insurance can purchase coverage.
Inpatient Care
Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Surgery
A surgical procedure that requires an overnight stay in a hospital or clinical setting.
L
Lawfully Present
A term used to describe immigrants that have a valid non-immigrant status and are able to purchase coverage through the NY State of Health.
Lifetime Limit
The total amount a health plan will pay for an individual over the course of his or her life. Costs above the lifetime maximum must be paid by the individual.
M
Mail Order
A pharmacy that dispenses and delivers prescription drug through the mail instead of through a retail store.
Managed Care Plan
A health plan that features a network of physicians, hospitals, and other providers who participate in the plan. This type of health care delivery system operates with the aim of coordinating a continuum of care while also controlling costs. Some managed care plan types use a primary care physician to act as a gatekeeper through whom the patient has to go through to see a specialist. This acts as a mechanism to control utilization of health services. In some plans, you can only see an in-network provider; in other plans, you may go out-of-network, but you will generally pay more.
Maximum Out-of-Pocket (MOOP)
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount for covered care. Generally, this includes the deductible, coinsurance, and co-payments. This limit never includes your premium, additional charges for care received out-of-network, or health care your plan doesn't cover.
Maximum Lifetime Benefit
The total amount a health plan will pay for an individual over the course of his or her life. Costs above the lifetime maximum must be paid by the individual.
Medicaid
A jointly funded program by the federal and state governments designed to provide coverage for medical and health-related services for eligible low-income adults and children.
Medically Necessary
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, disease or its symptoms and that meet accepted standards of medicine.
Metal Tiers
Health plans offered in the Marketplace will fall into categories called metal tiers. The metal tiers are bronze, silver, gold and platinum, and are associated with the actuarial value of the plan.
Minimum Essential Coverage (MEC)
Any health Insurance that meets the Affordable Care Act requirement to have coverage. If you have MEC, you don't have to pay the fee for being uninsured. Some examples include: eligible employer-sponsored plan, plans purchased in the Marketplace, most plans bought directly from an insurer, job-based insurance, Medicare, Medicaid, Child Health Plus, Essential Plan, TRICARE, COBRA and other defined coverage.Modified Adjusted Gross Income (MAGI)
The methodology used to determine income eligibility for tax credits to lower health plan costs in the Marketplace and for Medicaid and Child Health Plus. Generally, for tax credits, modified adjusted gross income is the adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you and the members of your household received during the year. Medicaid and Child Health Plus use a similar methodology for determining income eligibility but with a few differences.
N
Navigator
An individual or organization that is funded, trained and certified by the State of New York to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased and offer their services free of charge.
Network
Refer to Provider Network
Non-discrimination Testing
An objective legal test to determine the fairness of a Section 125 plan and to ensure businesses comply with Internal Revenue Service (IRS) non-discrimination rules. IRS rules are intended to ensure that Section 125 plan benefits are equally offered and utilized by the entire eligible employee population.
Non-formulary Drugs
Prescription drugs that are not included on a health plan's list of preferred drugs (formulary). Some health plans allow consumers to use non-formulary drugs, but these drugs may cost more than drugs on the formulary.
NY State of Health
The official health plan marketplace in the State of New York. Created by Governor Cuomo through an Executive Order as part of the state's implementation of the Affordable Care Act, it sits within the NYS Department of Health. NY State of Health allows individual and small businesses to shop, compare, and enroll in qualified health plans. It is the only place individuals and small businesses can receive financial assistance through tax credits.
O
Office Visit
A visit to a provider outside of the hospital. Such visits may include annual physicals, check-ups and sick visits. These include visits to both primary care physicians and specialists.
Out-of-network
Doctors, hospitals, pharmacies, and other health services practitioners who do not have an agreement with your health insurance plan to offer you services and supplies at a price agreed upon with your health plan (usually a discounted price).Outpatient Care
Health care that doesn't require an overnight stay in a hospital or other health care facility.
Outpatient Surgery
A surgical procedure that does not require an overnight stay in a hospital or clinical setting. This is also sometimes referred to as ambulatory surgery.
P
Plan Document
An official document stating the terms of a Section 125 plan. It includes a formal agreement between employee and employer to reduce the employee's salary by a pre-determined amount in order to contribute to a Section 125 plan.
Plan Type
A term used to describe the structure and arrangement of your health plan, such as fee-for-service, health maintenance organization (HMO), point-of-service (POS), exclusive provider organization (EPO), preferred provider organization (PPO).
Plan Year
For a Section 125 plan (cafeteria plan), the plan year must be 12 consecutive months and must be established in the written plan. A short plan year is permitted only for certain business purposes.
Point-of-service Plan (POS)
A type of managed care plan, POS plans allow you to seek care from providers both in-network and out-of-network, although you generally pay less for in-network care and more for out-of-network care. POS plans require you to designate an in-network provider to be your primary care physician. Some plans require that you obtain a referral from your primary care physician to see a specialist.
Pre-existing Condition
A medical condition that occurred before a program of health benefits went into effect. Under the Affordable Care Act, insurers cannot deny or delay coverage of such conditions when providing health coverage.
Preferred Provider Organization (PPO)
A type of managed care plan, PPO plans give you flexibility in choosing physicians and other providers. You do not need a referral from a primary care physician to see a specialist. You can go to providers that are both in-network and out-of-network. You usually pay more out-of-pocket when you go out-of-network.
Premium
The amount you pay to belong to a health plan. Premiums are usually paid each month.
Premium-only-plan (POP)
A type of Section 125 plan that allows employees to use a portion of their pre-tax earnings to pay for health insurance premiums.
Premium Tax Credit
A new refundable and advanceable tax credit under the Affordable Care Act that lowers the cost of private health insurance for eligible individuals It is only available for coverage purchased through the marketplace. Individuals can choose either use the tax credit right away to lower their monthly premiums or claim it when they file their federal income tax return at the end of the year.
Prescription (Rx) Drug
A health care provider's authorization for a pharmacist to prepare and dispense medication.
Prescription Drug Coverage
Health insurance coverage for some or all of the cost of generic and brand name drugs.
Preventive Care
Care that seeks to keep a health problem from developing or to diagnose a problem early. Preventive care may include routine physicals, well-baby care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other early detection testing. Under the Affordable Care Act, non-grandfathered health plans must cover certain preventive care services and not charge the patient anything when he or she receives the service.
Primary Care Physician (PCP)
A provider you visit for routine care, usually a family practice doctor, internist, obstetrician-gynecologist, or pediatrician. Some health plans, such as health maintenance organization (HMO) and point-of-service (POS) plans require you to choose a PCP to coordinate your care and refer you to a specialist.
Prior Authorization
Some health plans require you to get approval from your primary care physician or directly from the health plan before you receive care.
Private Nursing
A contracted service where a nurse visits the patient's place of residence to assist with personal medical needs in accordance with physician orders.
Provider
A doctor, hospital, health care practitioner, pharmacy, or health care facility licensed, certified, or accredited as required by state law.
PRUCOL – Permanently Residing under the Color of Law
A public benefits category applied to certain immigrants for the purpose of obtaining select health insurance coverage, including Medicaid. The immigrant must meet the program's income and other eligibility requirements. PRUCOL is not recognized as an immigration status by the US Citizenship and Immigration Services (USCIS).
Provider Network
A group of medical providers who have agreed to provide a health plan's members with services and supplies at a discounted rate. Provider networks vary between health plans.Q
Qualified Health Plans
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the NY State of Health, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.
R
Referral
When a medical provider recommends you see another provider. The most common type of referral is from a primary care physician (PCP) to a specialist.
S
Schedule C
The U.S. federal income tax form on which profit and loss from an unincorporated business is listed.
Section 125 Plan
Refer to Cafeteria Plan
Self-Employed
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
Small Business
For health insurance purposes in New York, businesses that employ between 2 and 100 workers, including owners.
Small Business Health Options Program (SHOP)
Name of the NY State of Health marketplace program open to small businesses with 2-50 employees. Businesses can receive a premium tax credit through, and only through the SHOP.
Sole Proprietor
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
Specialist
A doctor who has been specially trained in and practices a specific type of medicine other than primary care, such as a cardiologist or dermatologist.
Spouse
A married person. For health insurance purposes, a spouse can be of the same or an opposite sex.
Subscriber
The person responsible for making premium payments or whose employment makes him or her eligible for a health plan.
Subsidies
Under the Affordable Care Act, financial assistance that lowers health insurance costs for eligible individuals. They can include tax credits to lower monthly premium costs and subsidies that reduce the amount of cost-sharing required for eligible individuals.
Surgical Inpatient Care
Care provided to you after undergoing an inpatient surgery, which helps you recover.
U
Undocumented Individuals
Individuals, who did not have official documents to enter, live in or work in the U.S. legally. Includes individuals who entered the U.S. without inspection (EWIS) and those who overstayed their visa.
Urgent Care
Medical treatment for conditions that require prompt medical attention, but are not life-threatening emergencies.
Usual, Customary, and Reasonable Fee
The prevailing cost of a medical service in a given geographic area that an insurance plan is willing to pay.
W
W-2
A form given to an employee by his or her employer by January 31 of each year showing the amounts of income and money withheld for the previous calendar year.
Wellness Plan/Program
Employment-based program to promote health and prevent chronic disease. Goals of these programs include: reducing health care costs, sustaining and improving employee health and productivity, and reducing absenteeism due to illness.
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1099 Workers
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
A
Actuarial Value
Actuarial value is the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, the consumer would be responsible for, on average, 30% of the costs of all covered benefits.
Affordable Care Act (ACA)
The health care reform law enacted under President Obama in March 2010. The ACA aims to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of health care for individuals and the government. It provides a number of mechanisms—including mandates, subsidies, and insurance exchanges—to increase coverage and affordability.
Appeal
A request for your health insurer or plan to review a decision to deny payment for health care services that they have initially determined to be not medically necessary, experimental, or, in certain cases, out-of-network.
B
Benefit
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Brand Name Drug
A prescription drug that received a patent on its chemical entity, formulation, or use and has been approved by the Food and Drug Administration after clinical testing. When patents expire, generic versions of brand name drugs may be offered under a different name and often at lower costs.
Broker
A licensed professional who helps businesses and individuals select and purchase a health plan. Those brokers that choose to sell products in the Marketplace are trained and certified by the NY State Department of Health to complete applications on NY State of Health and receive commission-based compensation. Due to their commission-based compensation, these entities may be biased as to the products they sell since they are paid directly from the insurers. Brokers can choose to certify in the Small Business Marketplace, Individual, or both.
C
Cafeteria Plan
Cafeteria plans, also known as Section 125 plans, allow employees to choose between receiving cash (in the form of earnings) and paying for health insurance and other qualified benefits with pre-tax earnings. For example, one type of Section 125 plan, a premium-only-plan (POP), allows employees to pay for health insurance before taxes, which lowers the amount of the employee's salary subject to federal, state and local income taxes. Section 125 plans also lower the employer's payroll taxes (FICA or Social Security and Medicare taxes).Carrier
A company or organization that offers health insurance plans.
Catastrophic Health Plan
Under the Affordable Care Act, a health plan geared towards people under 30 and some people with limited incomes. It meets all the requirements applicable to other Qualified Health Plans (QHPs) in the Marketplace but does not cover any benefits other than 3 primary care visits per year before the plan's deductible is met.
Certified Application Counselor (CAC)
Individuals that are trained and certified by the NY State Department of Health to conduct community outreach and complete applications in the NY Sate of Health Marketplace. Unlike navigators, they do not receive compensation from the state, but rather directly from the entity in which they are employed, which may lead to a conflict of interest when it comes to being unbiased about the plan options offered to potential clients.
Child Health Plus (CHP)
A public health insurance program for children under the age of 19, regardless of their immigration status, that covers a wide range of children's health care and dental needs. Based upon family income, children may qualify for free or low-cost health insurance through this program.
Chiropractic Care
A type of care where the spine is manipulated to relieve pressure on nerves, muscle spasms of the back and neck, tension headaches, and some types of leg pain.
Claim
The bill you or your provider sends to the health plan for health care services that you received.
Co-payment (Co-pay)
A fixed dollar amount paid by an individual at the time of receiving a covered health care service from a participating provider. The required fee varies by the service provided and by the health plan.
COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
A federal law that allows you to continue health insurance coverage offered by your previous employer usually for up to 18 months after leaving a job. With COBRA coverage, you must pay the full cost of your health coverage and you may be charged a small administrative cost.
Coinsurance
The portion or percent of health care costs that you're required to pay. For example, the health insurer or plan may cover 80% of charges for a covered hospitalization, leaving you responsible for the other 20%. This 20% is known as the co-insurance.
Consumer Operated and Oriented Plans (Co-Op)
A non-profit, member-run health insurance organization that provides insurance coverage to individuals and small businesses through health insurance exchanges and can operate at state, regional, and national levels.
Cost-Sharing
The amount the patient pays for covered health care. Depending on the plan, cost-sharing could include deductibles, co-payments or coinsurance. This does not include premiums or the cost of non-covered or out-of-network services.
Covered Benefit
The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
D
Deductible
The amount you must pay for covered health care services, before your health plan begins to pay. You typically must pay a deductible each year. There may be separate deductibles for different types of services, and many plans have no deductible.
Dependent
A person covered under a private health plan who is not primary enrollee or policyholder, usually a spouse or child. In New York State, many plans offered by employers also cover domestic partners.
Diagnostic Exams and Lab Fees
The fees that you pay for laboratory tests (such as blood work and urine tests) and imaging tests (such as x-ray, ultrasound, CT scan, and MRI).
Domestic Partners
A legal relationship permitted under the laws of the State and City of New York for couples that have a close and committed personal relationship. The Domestic Partnership Law recognizes the diversity of family configurations, including lesbian, gay, and other non-traditional couples.
Drug Coverage
Refer to Prescription (Rx) Drug
Drug Maximum per Calendar Year
The total annual amount that a health plan will pay for your prescription (Rx) drugs for the year. If the total cost of your prescriptions is more than the drug maximum in the year, you will have to pay the additional cost. Many plans do not have a drug maximum.
Durable Medical Equipment (DME)
Equipment used in the course of treatment or home care, including items such as crutches, knee braces, wheelchairs, hospital beds and prostheses.
E
Effective Date
The date on which insurance benefits begin.
Emergency
An injury, symptom, or illness that requires immediate medical attention.
Emergency Care
Care for a sudden medical or behavioral condition that a prudent layperson could reasonably expect to result in placing the person's health in serious jeopardy or causing serious bodily or mental dysfunction or damage.
Emergency Room or Emergency Department
The area in a hospital or clinic staffed and equipped to provide emergency care to persons requiring immediate medical treatment.
Employee
A person who is hired for a wage, salary, or other payment to perform work for an employer. An employee generally receives a W-2 statement from his or her employer. An employee can work on a full-time (usually 35 or more hours a week) or part-time (less than the standard hours for full-time work) basis.
Employer Health Care Tax Credit
An incentive designed by the ACA to encourage employers, usually small employers with fewer than 25 employees, to offer health insurance to their employees. The tax credit enables employers to deduct an amount, usually a percentage of the contribution they make toward their employees' premiums, from the federal taxes they owe. These tax credits are typically refundable so they are available to non-profit organizations that do not pay federal taxes.
Employer Mandate
Businesses with 50 or more full-time (or full-time equivalent) employees that don't offer insurance, or offer coverage that doesn't meet certain minimum standards, may be subject to a fee. Learn more about the Employer Shared Responsibility Payment from the IRS.
Refer to Health Insurance Mandate
EPO (Exclusive Provider Organization)
A type of managed care plan, EPOs typically require you to receive care from in-network providers. You do not need a referral from a primary care physician to see a specialist. Out-of-network care is generally not covered.
Essential Health Benefits
A package of benefits set by the Secretary of Health and Human Services and defined by the State of New York that individual and small group market insurers will be required to offer under the Affordable Care Act starting in 2014
Essential Plan
Free or very low cost insurance for adults with low income who don't qualify for Medicaid.
Exemptions
You may be exempt from the requirement to obtain health insurance and will not have to pay the fee when you file your federal income tax return. Find an exemption that may apply to you.Exclusions/Limitations
refers to anything an insurance company will not cover, ranging from a type of drug to a type of surgery. Exclusions can vary from plan to plan.
Explanation of Benefits (EOB)
A summary of a medical care claim. The EOB shows the service rendered; the provider's charge, the insurer's negotiated or allowable charge, how much the insurance company has paid and any balance you must pay. It also includes an explanation of any denial, reduction, or other reason for not providing full reimbursement for the amount claimed; and information on how to file an appeal.
F
Family Planning Benefit Program (FPBP)
The Family Planning Benefit Program (FPBP) is a free and completely confidential New York State program that provides family planning services to teens, women, and men who meet certain income and residency requirements, and who are not enrolled in Medicaid or Family Health Plus.
Federal Poverty Level (FPL)
The set minimum amount of gross income that a family needs for food, clothing, transportation, shelter, and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Medicaid and other programs in the U.S. define eligibility income limits as some percentage of FPL.
Financially Interdependent
The individuals in a domestic partnership are jointly responsible for the financial obligations of the partnership. Insurance carriers may require domestic partners, as an eligibility requirement for coverage, to demonstrate that they are financially interdependent through the submission of documents including but not limited to: a joint mortgage or lease for their place of residence, an agreement for a joint bank or credit account, and mutual grants of power of attorney. Each insurance carrier sets its own documentation requirements.
Flexible Spending Account (FSA)
A type of cafeteria plan (Section 125 Plan) that allows employees to pay for qualified benefits with pre-tax earnings. Qualified benefits include dependant care assistance, adoption assistance, and qualified medical care reimbursements.
Formulary
A list of both generic and brand name drugs that are preferred by your health plan. Your plan may charge you more for drugs that are not included on the formulary (non-formulary drugs) or limit your choices to drugs on the formulary.
Freelancer
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
G
Gatekeeper
Some plans require you to select a primary care physician (PCP) who provides you with basic medical services, coordinates medical care, and refers you to specialists.
Generic Drug
A drug that is similar to a brand name drug. Generic drugs are approved by the Food and Drug Administration if they contain the same active ingredients and have comparable therapeutic effectiveness to a brand name drug. Generic drugs are developed after the patent on a brand name drug has expired and are usually less expensive than brand name drugs.
Grandfathered Plans
Grandfathered plans are those that were in existence on March 23, 2010, and have stayed basically the same. But they can enroll people after that date and still maintain their grandfathered status. In other words, even if you joined a grandfathered plan after March 23, 2010, the plan may still be grandfathered. The status depends on when the plan was created, not when you joined it.
Group Insurance
Health coverage available to individuals based on their affiliation with an employer.
Guarantee Issue/Renewal
Requires insurers to offer and renew coverage, without regard to health status, use of services, or pre-existing conditions.
H
Health Care
Health care is the services you receive from a doctor or another provider to stay healthy or to treat an illness or injury.
Health Insurance
Health insurance is a way to pay for health care. You pay a monthly fee, or premium, to an insurance company. In return, they pay a portion of your health care costs.
Health Insurance Mandate
The Affordable Care Act health care law requires you and everyone in your family, including children, to have qualifying health insurance (known as minimum essential (MEC) coverage) in each month of the year. If you don't have a health plan that qualifies as minimum essential coverage, you may have to pay a fee for the months without coverage (The fee is also called the "fine" or "penalty." For 2016 the penalty is the higher of these two amounts: 2.5% of your household income; or $695 per adult ($347.50 per child), up to a maximum of $2,085. You'll pay the penalty on your federal income tax return. People with very low incomes and others may be eligible for exemptionsHealth Insurance Policy
The terms, conditions, benefits, and obligations of your health plan.
Health Savings Account (HSA)
A financial account established by an employer or an individual that can be used to pay for qualified medical expenses on a tax-free basis. You must be covered by a high deductible health plan (HDHP) that meets certain requirements set by the federal government to establish and contribute to an HSA, and you cannot have other health coverage or be eligible for Medicare.
Healthy New York (HNY) Program
A NYS subsidized health insurance plan that provides comprehensive and lower-cost health insurance coverage to individuals, sole proprietors, and small businesses that meet the program's eligibility requirements. Please note: Healthy NY coverage for Individuals and Sole Proprietors will terminate December 31, 2013.
High Deductible Health Plan (HDHP)
A health plan that requires you to pay more out-of-pocket for services before the health plan starts paying. For individuals to open a health savings account (HSA), they must be enrolled in a HDHP that meets certain requirements set by the federal government, including requirements on the deductible and annual out-of-pocket costs.
HMO (Health Maintenance Organization)
A type of managed care plan that typically requires you to receive care from in-network providers. Some plans require that you obtain a referral from your primary care physician before you can see a specialist. Out-of-network care is generally not covered.
Home Health Care
Health care or supportive care provided in the patient's home usually by healthcare professionals.
Hospice Care
Care provided to people in the final phase of a terminal illness that focuses on comfort and quality of life, rather than cure.
Hospital Inpatient Care
Care that requires a stay in a hospital, usually overnight.
Hospital Outpatient Care
Care that does not require an overnight stay in a hospital and is often provided in a hospital outpatient clinic.
Hospital Stay
The length of time from admission into a hospital until discharge.
I
In-network
Doctors, hospitals, pharmacies, and other health care practitioners that have agreed to provide members of a health plan with services and supplies at a discounted price. Under some health plans, your care is covered only if you receive it from in-network providers.In-Person Assistors
Individuals or organizations that are trained and certified by the State of New York to provide help to consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including helping them complete eligibility and enrollment forms. Their services are free to consumers. These entities include Navigators, Brokers, and Certified Application Counselors.
Individual/Direct Pay Health Insurance
Coverage that you purchase on your own and not as part of a group or through your employment. Also referred to as direct pay health insurance.
Individual Mandate
A requirement under the Affordable Care Act that all individuals who do not have health insurance coverage must obtain coverage by January 1, 2014, or pay a penalty, unless they can and do claim an exemption.
Individual Insurance Marketplace
The place where individuals and sole proprietors who do not have adequate health insurance can purchase coverage.
Inpatient Care
Health care that you get when you're admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.
Inpatient Surgery
A surgical procedure that requires an overnight stay in a hospital or clinical setting.
L
Lawfully Present
A term used to describe immigrants that have a valid non-immigrant status and are able to purchase coverage through the NY State of Health.
Lifetime Limit
The total amount a health plan will pay for an individual over the course of his or her life. Costs above the lifetime maximum must be paid by the individual.
M
Mail Order
A pharmacy that dispenses and delivers prescription drug through the mail instead of through a retail store.
Managed Care Plan
A health plan that features a network of physicians, hospitals, and other providers who participate in the plan. This type of health care delivery system operates with the aim of coordinating a continuum of care while also controlling costs. Some managed care plan types use a primary care physician to act as a gatekeeper through whom the patient has to go through to see a specialist. This acts as a mechanism to control utilization of health services. In some plans, you can only see an in-network provider; in other plans, you may go out-of-network, but you will generally pay more.
Maximum Out-of-Pocket (MOOP)
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount for covered care. Generally, this includes the deductible, coinsurance, and co-payments. This limit never includes your premium, additional charges for care received out-of-network, or health care your plan doesn't cover.
Maximum Lifetime Benefit
The total amount a health plan will pay for an individual over the course of his or her life. Costs above the lifetime maximum must be paid by the individual.
Medicaid
A jointly funded program by the federal and state governments designed to provide coverage for medical and health-related services for eligible low-income adults and children.
Medically Necessary
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, disease or its symptoms and that meet accepted standards of medicine.
Metal Tiers
Health plans offered in the Marketplace will fall into categories called metal tiers. The metal tiers are bronze, silver, gold and platinum, and are associated with the actuarial value of the plan.
Minimum Essential Coverage (MEC)
Any health Insurance that meets the Affordable Care Act requirement to have coverage. If you have MEC, you don't have to pay the fee for being uninsured. Some examples include: eligible employer-sponsored plan, plans purchased in the Marketplace, most plans bought directly from an insurer, job-based insurance, Medicare, Medicaid, Child Health Plus, Essential Plan, TRICARE, COBRA and other defined coverage.Modified Adjusted Gross Income (MAGI)
The methodology used to determine income eligibility for tax credits to lower health plan costs in the Marketplace and for Medicaid and Child Health Plus. Generally, for tax credits, modified adjusted gross income is the adjusted gross income plus any tax-exempt Social Security, interest, or foreign income you and the members of your household received during the year. Medicaid and Child Health Plus use a similar methodology for determining income eligibility but with a few differences.
N
Navigator
An individual or organization that is funded, trained and certified by the State of New York to help consumers, small businesses, and their employees as they look for health coverage options through the Marketplace, including completing eligibility and enrollment forms. These individuals and organizations are required to be unbiased and offer their services free of charge.
Network
Refer to Provider Network
Non-discrimination Testing
An objective legal test to determine the fairness of a Section 125 plan and to ensure businesses comply with Internal Revenue Service (IRS) non-discrimination rules. IRS rules are intended to ensure that Section 125 plan benefits are equally offered and utilized by the entire eligible employee population.
Non-formulary Drugs
Prescription drugs that are not included on a health plan's list of preferred drugs (formulary). Some health plans allow consumers to use non-formulary drugs, but these drugs may cost more than drugs on the formulary.
NY State of Health
The official health plan marketplace in the State of New York. Created by Governor Cuomo through an Executive Order as part of the state's implementation of the Affordable Care Act, it sits within the NYS Department of Health. NY State of Health allows individual and small businesses to shop, compare, and enroll in qualified health plans. It is the only place individuals and small businesses can receive financial assistance through tax credits.
O
Office Visit
A visit to a provider outside of the hospital. Such visits may include annual physicals, check-ups and sick visits. These include visits to both primary care physicians and specialists.
Out-of-network
Doctors, hospitals, pharmacies, and other health services practitioners who do not have an agreement with your health insurance plan to offer you services and supplies at a price agreed upon with your health plan (usually a discounted price).Outpatient Care
Health care that doesn't require an overnight stay in a hospital or other health care facility.
Outpatient Surgery
A surgical procedure that does not require an overnight stay in a hospital or clinical setting. This is also sometimes referred to as ambulatory surgery.
P
Plan Document
An official document stating the terms of a Section 125 plan. It includes a formal agreement between employee and employer to reduce the employee's salary by a pre-determined amount in order to contribute to a Section 125 plan.
Plan Type
A term used to describe the structure and arrangement of your health plan, such as fee-for-service, health maintenance organization (HMO), point-of-service (POS), exclusive provider organization (EPO), preferred provider organization (PPO).
Plan Year
For a Section 125 plan (cafeteria plan), the plan year must be 12 consecutive months and must be established in the written plan. A short plan year is permitted only for certain business purposes.
Point-of-service Plan (POS)
A type of managed care plan, POS plans allow you to seek care from providers both in-network and out-of-network, although you generally pay less for in-network care and more for out-of-network care. POS plans require you to designate an in-network provider to be your primary care physician. Some plans require that you obtain a referral from your primary care physician to see a specialist.
Pre-existing Condition
A medical condition that occurred before a program of health benefits went into effect. Under the Affordable Care Act, insurers cannot deny or delay coverage of such conditions when providing health coverage.
Preferred Provider Organization (PPO)
A type of managed care plan, PPO plans give you flexibility in choosing physicians and other providers. You do not need a referral from a primary care physician to see a specialist. You can go to providers that are both in-network and out-of-network. You usually pay more out-of-pocket when you go out-of-network.
Premium
The amount you pay to belong to a health plan. Premiums are usually paid each month.
Premium-only-plan (POP)
A type of Section 125 plan that allows employees to use a portion of their pre-tax earnings to pay for health insurance premiums.
Premium Tax Credit
A new refundable and advanceable tax credit under the Affordable Care Act that lowers the cost of private health insurance for eligible individuals It is only available for coverage purchased through the marketplace. Individuals can choose either use the tax credit right away to lower their monthly premiums or claim it when they file their federal income tax return at the end of the year.
Prescription (Rx) Drug
A health care provider's authorization for a pharmacist to prepare and dispense medication.
Prescription Drug Coverage
Health insurance coverage for some or all of the cost of generic and brand name drugs.
Preventive Care
Care that seeks to keep a health problem from developing or to diagnose a problem early. Preventive care may include routine physicals, well-baby care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other early detection testing. Under the Affordable Care Act, non-grandfathered health plans must cover certain preventive care services and not charge the patient anything when he or she receives the service.
Primary Care Physician (PCP)
A provider you visit for routine care, usually a family practice doctor, internist, obstetrician-gynecologist, or pediatrician. Some health plans, such as health maintenance organization (HMO) and point-of-service (POS) plans require you to choose a PCP to coordinate your care and refer you to a specialist.
Prior Authorization
Some health plans require you to get approval from your primary care physician or directly from the health plan before you receive care.
Private Nursing
A contracted service where a nurse visits the patient's place of residence to assist with personal medical needs in accordance with physician orders.
Provider
A doctor, hospital, health care practitioner, pharmacy, or health care facility licensed, certified, or accredited as required by state law.
PRUCOL – Permanently Residing under the Color of Law
A public benefits category applied to certain immigrants for the purpose of obtaining select health insurance coverage, including Medicaid. The immigrant must meet the program's income and other eligibility requirements. PRUCOL is not recognized as an immigration status by the US Citizenship and Immigration Services (USCIS).
Provider Network
A group of medical providers who have agreed to provide a health plan's members with services and supplies at a discounted rate. Provider networks vary between health plans.Q
Qualified Health Plans
Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by the NY State of Health, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements.
R
Referral
When a medical provider recommends you see another provider. The most common type of referral is from a primary care physician (PCP) to a specialist.
S
Schedule C
The U.S. federal income tax form on which profit and loss from an unincorporated business is listed.
Section 125 Plan
Refer to Cafeteria Plan
Self-Employed
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
Small Business
For health insurance purposes in New York, businesses that employ between 2 and 100 workers, including owners.
Small Business Health Options Program (SHOP)
Name of the NY State of Health marketplace program open to small businesses with 2-50 employees. Businesses can receive a premium tax credit through, and only through the SHOP.
Sole Proprietor
For health insurance purposes in New York, an individual who works for himself or herself instead of working for an employer that pays a salary or a wage.
Specialist
A doctor who has been specially trained in and practices a specific type of medicine other than primary care, such as a cardiologist or dermatologist.
Spouse
A married person. For health insurance purposes, a spouse can be of the same or an opposite sex.
Subscriber
The person responsible for making premium payments or whose employment makes him or her eligible for a health plan.
Subsidies
Under the Affordable Care Act, financial assistance that lowers health insurance costs for eligible individuals. They can include tax credits to lower monthly premium costs and subsidies that reduce the amount of cost-sharing required for eligible individuals.
Surgical Inpatient Care
Care provided to you after undergoing an inpatient surgery, which helps you recover.
U
Undocumented Individuals
Individuals, who did not have official documents to enter, live in or work in the U.S. legally. Includes individuals who entered the U.S. without inspection (EWIS) and those who overstayed their visa.
Urgent Care
Medical treatment for conditions that require prompt medical attention, but are not life-threatening emergencies.
Usual, Customary, and Reasonable Fee
The prevailing cost of a medical service in a given geographic area that an insurance plan is willing to pay.
W
W-2
A form given to an employee by his or her employer by January 31 of each year showing the amounts of income and money withheld for the previous calendar year.
Wellness Plan/Program
Employment-based program to promote health and prevent chronic disease. Goals of these programs include: reducing health care costs, sustaining and improving employee health and productivity, and reducing absenteeism due to illness.