Health Insurance Vocabulary - PEU

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Health Insurance
Vocabulary

Health insurance language can be confusing, but GetCoveredNYC is here to help!

GetCoveredNYC Specialists are here to make health insurance easy to navigate, and that includes helping New Yorkers understand complicated terms and phrases. Understanding the ins and outs of health insurance (including definitions) helps you make better, more informed choices. GetCoveredNYC helps you take ownership over your health. Let's get started!

Learn more about health insurance terms below and reach out to GetCoveredNYC for one-on-one support. Have questions about health insurance? Contact GetCoveredNYC

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Definitions

Behavioral Health Care: Behavioral health care includes treatment and rehabilitation services for mental health issues and substance use disorders. Behavioral health issues can affect how you handle stress, relate to others, and make choices; if you are experiencing a behavioral health issue, you may be notice changes in your thinking behavior or mood.

COBRA: A law that lets you keep the health insurance offered by your employer after you leave a job (usually for up to 18 months). With COBRA coverage, you have to pay the full cost of your health coverage, and you might have to pay a small, additional administrative cost.

Co-Payment: Also called a co-pay, this is a fixed amount of money ($20, for example) that you pay for a covered health care service. Annual check-ups and wellness visits are free (no deductible or co-pays). The required fee varies by the service provided and by the health plan.

Co-Insurance: The amount of money you have to pay for health care, in addition to what your insurance pays. For example, your health plan might cover 80% of your hospital bill, and you would have to cover 20%. This 20% is your co-insurance.

Deductible: The amount of money that you have to pay for covered health care services before your health plan kicks in. Annual check-ups and wellness visits are free (no deductible or co-pays). There may be separate deductibles for different types of services, and many plans have no deductible. For example, if you have a $2,000 deductible, you have to pay the first $2,000 for certain services yourself. You usually have to pay your deductible every year and payments for services that aren't covered by your insurance do not count toward your deductible.

Essential Plan: The Essential Plan is low-cost health insurance for eligible New Yorkers. It includes coverage for doctors visits, hospital care, screenings, prescriptions, dental care, and vision benefits. There is no monthly premium or deductible. You can enroll at any time during the year through the NY State of Health.

Health Maintenance Organization (HMO): A type of health insurance plan that requires you to get your care from a predetermined network of providers. HMOs usually don't cover out-of-network costs, so you can only see doctors who accept your plan. Some HMO plans require you to get a referral from your primary care physician before you can see a specialist.

In-Network: A group of doctors, facilities, and suppliers that accept your health insurance plan. They have a special agreement to provide cheaper services and supplies to people with your health insurance.

Preventive Care: This kind of care helps people stay healthy! Examples include annual doctor's check-ups and screenings. 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.

Marketplace: The Health Insurance Marketplace is a website where people can enroll in health insurance. In New York State, the marketplace is NY State of Health. Learn more at nystateofhealth.ny.gov

Out-of-Pocket Maximum: The most you will possibly have to pay for covered services in a year. After you pay this amount, your health insurance will cover 100% of the costs for covered care. Generally, this includes the deductible, co-insurance, and co-pays. This limit never includes your premium, additional charges for care received out-of-network, or health care your plan doesn't cover.

Out-of-Network: A group of doctors, facilities, and suppliers who do not accept your health insurance plan. Depending on the type of health insurance that you have, you will have to pay more or all of the entire bill from an out-of-network provider.

Open Enrollment: The NY State of Health open enrollment period is a specific time each year when people can sign up for or change their health insurance plans. This period is crucial for those needing to enroll in a new plan, switch, or change their existing coverage.

Premium: The amount you pay (usually every month) for your health insurance plan. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, co-payments, and co-insurance. If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit.

Qualified Health Plan: An insurance plan that is certified by the NY State of Health and follows the rules set by the Affordable Care Act (also known as Obamacare). These plans are not free, but premium tax credits are available to help make them more affordable for those who qualify.

Premium Tax Credit: A type of tax credit that makes private health insurance more affordable for those who qualify. It is only available for coverage purchased through the marketplace (NY State of Health). Individuals can choose either to 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. Your tax credit is based on the income estimate and household information you put on your Marketplace application.

Preferred Provider Organization (PPO): A type of health insurance plan that gives you more flexibility in choosing your health care providers. You do not need a referral from a primary care physician to see a specialist. You can go to doctors that are both in-network and out-of-network. Out-of-network doctors usually cost more.

Primary Care Physician (PCP): A doctor who you visit for routine care. Examples of this include a family practice doctor, gynecologist, or pediatrician. Some health insurance plans, like HMOs, require you to choose a PCP to coordinate your care and refer you to a specialist.

Special Enrollment: A special enrollment period (SEP) is a time outside of the regular open enrollment period when you can sign up for health insurance or make changes to your current plan if you experience certain life events. These events include getting married, having a baby, losing other health coverage, or moving to a new area.

For more, you can also visit the Human Resource Administration's Office of Citywide Health Insurance Access' resource called “Insurance A-Z," which provides definitions for common health insurance terms and phrases.