NYC Health Benefits Program

Glossary of Important Terms

 

Plan Type

Exclusive Provider Organization (EPO) plans offer a higher level of choice and flexibility than many other managed care plans. Members can see any provider in the EPO network, which contains family and general practitioners as well as specialists in all areas of medicine. There is no need to choose a primary care physician and no referrals are necessary to see a specialist. An EPO provides members with an extensive local, national and worldwide network of providers.
There are no claim forms to fi le and members will never have to pay more than the copayment for covered services. There is no out-of-network coverage.

 

Point-of-Service (POS) plans offer the freedom to use either a network provider or an out-of network provider for medical and hospital care. If the subscriber uses a network provider, health care delivery resembles that of a traditional HMO, with prepaid comprehensive coverage and little out-of-pocket costs for services. When the subscriber uses an out-of-network provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive coverage and subject to deductibles and/or coinsurance.

 

Participating Provider Organization (PPO)/Indemnity plans offer the freedom to use either a network provider or an out-of-network provider for medical and hospital care. Participating Provider Organization (PPO)/Indemnity plans contract with health care providers who agree to accept a negotiated lower payment from the health plan, with copayments from the subscribers, as payment in full for medical services. When the subscriber uses a non-participating provider, the subscriber is subject to deductibles and/or coinsurance.

 

A Health Maintenance Organization (HMO) is a system of health care that provides managed, pre-paid hospital and medical services to its members. An HMO member chooses a Primary Care Physician (PCP) from within the HMO network, and the PCP manages all medical services, provides referrals, and is responsible for non-emergency admissions. Individuals and/or families who choose to join an HMO can receive health care at little or no out-of-pocket cost, provided they use the HMO’s doctors and facilities. Because the HMO provides all necessary services, there are usually no deductibles to meet or claim forms to fi le. In most plans, if a physician outside of the health plan is used without a referral from the PCP, the patient is responsible for all bills incurred.

 

Medicare Supplemental Plans allow for the use of any provider and reimburses the enrollee who may be subject to Medicare or plan deductibles and coinsurance.

 

Medicare HMO Plans are those in which medical and hospital care is only provided by the HMO. Any services, other than emergency services, that are received outside the HMO, that have not been authorized by the HMO, will not be covered by either the HMO or Medicare. Any cost incurred would be the responsibility of the enrollee.

 

 

Other Terms

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

 

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.

 

Deductible is the amount you are responsible for before the Health Plan begins to pay for covered services.

 

The Allowed Charge is the amount the health plan will reimburse you for covered services rendered by non-participating Providers.

 

Balance Billing is billing a member or other responsible party for the difference between the insurer's payment and the actual charge.

 

In-Network Provider/Supplier is a healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc., who has an agreement with health plan to provide covered services to members.

 

Non-Participating Provider is a healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc., who does not have an agreement with the health plan to provide covered services to members.

 

Out-of-Network Benefits are generally subject to a deductible and coinsurance and, therefore, have higher out-of-pocket costs. Depending on your contract, out-of-network services may not be covered. Please refer to your contract for specific benefit coverage.

 

Participating Provider/Network Provider is a participating provider is a physician or other Provider who has agreed to accept the health plan's scheduled or negotiated rates as payment in full or covered services (except for any applicable copayments, coinsurance or deductibles).

 

A Participating Provider is a member of the health plan network of Participating Providers applicable to your Certificate. Therefore, they are sometimes referred to as "Network Providers." Payment is made directly to a Participating Provider. Please consult your health plan directory to search for Participating Providers.