Insurance Terms Explained
Affordable Care Act: The 2010 health care law that seeks to increase access to health coverage for Americans and introduces new protections to those who have health insurance.
Affordable Care Advisor: Web application on the Fidelis Care website that lets potential members determine the coverage they need, as well as coverage affordability.
Authorization (pre-authorization or prior authorization): The approval of care, such as hospitalization. It may be required before a patient is admitted or care is given by (or reimbursed to) providers for certain services.
Behavioral health care: Mental health services, including services for drug and alcohol abuse.
Claim: A notice to the insurance company that a person received care covered by a health plan. A claim also may be a request for payment.
Coinsurance: An amount a member may be required to pay as their share of the cost for services or prescription drugs. Coinsurance is usually a percentage, such as 10 percent. Coinsurance often begins AFTER a plan deductible is met.
Copay, copayment: A copay/copayment is a fee that an individual pays for medical services that do not apply to the deductible.
Deductible: A portion of the covered expenses that an insured individual must pay before benefits are paid by a health plan. Deductibles are usually based on a calendar year.
Dependent: An individual who receives health insurance through a spouse, parent, or other family member.
Dual eligible: An individual who qualifies for Medicare and Medicaid coverage.
Enrollee: An individual who is a member of a health plan.
Essential Health Benefits: A set of standard benefits covered through NY State of Health Qualified Health Plans.
Explanation of Benefits (EOB): A form or document sent by a health plan to the member after a service has been provided and a claim has been paid to the provider. It is not a bill.
Formulary/drug formulary/prescription drug formulary: A list of prescription drugs (both generic and brand name) covered by a health plan.
Grace period: A set number of days past the due date of a premium payment during which medical coverage may not be canceled, and through which the premium payment may be made.
Grievance: The process by which an individual can air complaints and seek remedies.
Health Maintenance Organization (HMO): A comprehensive prepaid system of health care that emphasizes prevention, early detection of disease, and continuity of care. It is often used synonymously with “managed care plan.”
Medicaid Managed Care (MMC): Offers many New Yorkers a chance to choose a Medicaid health plan. Managed care plans focus on preventive health care and provide enrollees with a medical home for themselves and their families.
NY State of Health: The Official Health Plan Marketplace: A way for people to shop for, compare, and enroll in health coverage. It is the only place where individuals can receive financial assistance to lower the cost of coverage.
Open enrollment: A specified period of time in which individuals may change their insurance coverage. Open enrollment usually occurs once a year.
Out-of-pocket costs: Those health care expenses that are not reimbursed by a health insurance company. Common out-of-pocket costs include the deductible, co-pay, and co-insurance.
Out-of-pocket maximum: The most you’ll have to pay out of pocket for health care services in a given year. Out-of-pocket maximums can vary by plan. Deductibles, copays, and coinsurance costs all count toward your out-of-pocket maximum.
Premium: The money paid to an insurance company for coverage.
Primary Care Provider (PCP): A health care professional who coordinates most of the medical care for a patient. Some health plans require you to have a PCP, others do not.
Prior authorization: Approval in advance to get certain medical services or drugs that may or may not be on a plan’s formulary.
Referral: An action performed by your Primary Care Provider (PCP) that allows you to see another doctor if you need care that your PCP cannot provide. For example, if you need to see a specialist, your PCP will give you a referral that allows you to see a network specialist they recommend.