| 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. |
| 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. |
| Before Taxes | The amount of income received by a person or household before taxes are deducted. |
| 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. Brokers are paid, by health carriers, a portion of the health insurance premium (a commission) for enrolling individuals in a health plan. |
| Cafeteria Plan or Section 125 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. |
| Child Health Plus (CHP) | A public health insurance program for children under the age of 19 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. To learn more at Child Health Plus, go to http://www.nyc.gov/html/hia/html/public_insurance/children.shtml. |
| 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-pay or Co-payment | Some plans require you to pay a flat fee when you get medical care. You may pay different co-pays for different services. For example, you may pay $10 when you visit a primary care physician and $25 when you visit a specialist. |
| 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. Note: Due to limitations of the data sources used for our website, for small businesses, NYC Health Insurance Link shows the percent the health plan will pay. For individuals, NYC Health Insurance Link shows the percent that the individual will pay. |
| Cost-effective | An assessment made by the Local Department of Social Services relating to the Family Health Plus Premium Assistance program to determine if the health insurance coverage provided by the employer would cost less than the traditional Family Health Plus coverage. |
| 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 | Service or item that your health plan pays for in part or in full. |
| 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, insurers have the option of providing dependent coverage for unmarried children up to age 25. Many plans also cover domestic partners. |
| Dependent Child or Children | A child or children (under 21 years of age) for whom you have legal responsibility such as a son, daughter or adopted child. A foster child is not a dependent child. |
| 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 | See 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. |
| 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. |
| 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. |
| Exclusions | Services that are not covered by a health plan (sometimes called limitations). Exclusions and limitations should be clearly explained in plan documents. |
| 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. |
| Family Health Plus (FHP) | A public health insurance program for adults 19 to 64 years old who do not have other health insurance - either on their own or through their employers - but have incomes too high to qualify for Medicaid. For more information about Family Health Plus, go to http://www.nyc.gov/html/hia/html/public_insurance/adults.shtml. |
| Family Health Plus (FHP) Premium Assistance Program | A program that helps individuals eligible for Family Health Plus and have access to their employer’s qualified and cost-effective health insurance plan to pay for all or most of the cost of their share of health insurance to cover them and their family, including payment or partial payment of the premium, co-insurance, any deductible amounts, or co-payments. |
| 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 Insurance Contribution Act (FICA) | A federal employment payroll (salary and wages) tax of 15.3%. In a business, employers withhold FICA taxes from employees’ wages because employers and employees split the FICA tax equally. Each employee pays 7.65% and the employer pays the other 7.65%. Self employed persons pay the entire 15.3%. FICA taxes fund Social Security and Medicare. |
| Fee-for-service (FFS) Plan | A type of health plan in which doctors and other providers receive a fee/payment for each service such as an office visit, test, or procedure. When you need medical attention, you visit the doctor or hospital of your choice. There is no network, therefore there are no in-network or out-of-network restrictions as to the providers you visit. You do not need a referral to see a specialist. This plan gives you the most freedom and flexibility when selecting a provider, but is typically the most expensive type of plan. |
| 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. |
| 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. |
| Gross Taxable Income | This is your total salary before taxes or any other deductions are taken out. |
| Group Insurance | Health coverage available to individuals based on their affiliation with an employer, association, union, or other entity. |
| Health Care Provider | A doctor, hospital, community health center, skilled nursing facility or other entity that delivers health care services. |
| Health 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) | A health insurance program that is designed to assist small business owners in providing their employees and their employee's families with more affordable health insurance coverage. Uninsured sole proprietors and working individuals may also participate in this program. To qualify, income and other eligibility requirements must be met. For more information, please visit the Healthy NY page in NYC Health Insurance Link. |
| 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. |
| Highly Compensated Employee | As defined by the Internal Revenue Service, officers of the company, at least 5% shareholders, or those who are paid an annual salary of $110,000 or more (in 2009) are considered highly compensated employees. |
| HMO (Health Maintenance Organization) | A type of managed care plan, HMOs typically require 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. |
| Household | A person or group of people who live in the same residence and are considered together as a unit when applying for health insurance coverage or other benefits. |
| Household Income | The amount of money you and, if married, your spouse receive from wages and salary, child support/alimony, unemployment benefits, annuities, Social Security, worker's compensation, military pay, income from rent or room/board, and support from other family members. |
| Immediate Family | The smallest unit of a family that an individual lives with, which usually includes a father, a mother and siblings. |
| 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. |
| 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. |
| Inpatient Surgery | A surgical procedure that requires an overnight stay in a hospital or clinical setting. |
| Integrated Deductible | If the deductible is stated to be an "integrated deductible," then there is not a separate deductible for the benefit (for example drug coverage); you must meet the overall plan deductible ( i.e. annual deductible) before the plan will start paying toward your prescription drug costs. |
| Key Employee | As defined by the Internal Revenue Service, officers paid more than $160,000 (in 2009), at least 5% owners, or at least 1% owners with an annual salary of $160,000 or more are considered key employees. |
| Leased Employee | A staffing arrangement where a business owner (Business A) will transfer his/her employees to the payroll of an outside, independent employee leasing firm (Business B). This leasing firm (Business B) then leases the employee back to the original business (Business A). The original business (Business A) has full control over the duties and work of the leased employees, but the leasing firm (Business B) administers payroll and benefits and is responsible for most of the administrative functions typically performed by a human resources department. |
| 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 Annual Out-of-pocket | 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.
NOTE: Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments, or other expenses toward this limit. This definition may vary from plan to plan. For example, in some plans the out-of-pocket limit doesn't include cost-sharing for all services, such as prescription drugs. Also, plans may have different out-of-pocket limits for different services.
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| 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. |
| Maximum Out-of-pocket | The total amount of money you will have to pay in the event of major health problems. |
| Maximum Plan will Pay Per Year for Prescription Drugs | The maximum amount that a health plan will pay toward the cost of prescription drugs over a single year period. |
| 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. For more information about Medicaid, go to http://www.nyc.gov/html/hia/html/public_insurance/adults.shtml. |
| Medicaid for Pregnant Women | Medicaid Coverage for Pregnant Women is a comprehensive prenatal care program that offers complete pregnancy care and other health services to women and teens who live in New York State and meet income guidelines. |
| 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. |
| Mental or Nervous Disorder Care - Inpatient | Care that requires a stay in a hospital (usually overnight) for a mental or nervous disorder (non-physical disorder). |
| Mental or Nervous Disorder Care - Outpatient | Care for a mental or nervous disorder (non-physical disorder) that does not require an overnight stay in a hospital. |
| Monthly Household Income | The amount of income received by all adult members of the household before taxes are deducted including wages and salaries, self-employment income, unemployment benefits, social security benefits, child support and alimony payments. |
| Network | See "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. |
| Non-standard Worker | An individual who is engaged in a work arrangement that is not permanent, long-term, year-round or fulltime with a single employer. Workers who may fall into this category include, among others: agency temporary workers, contract company workers, day laborers, direct-hire temps, party-time workers, self-employed workers and on-call workers. |
| Office Visit | A visit to a provider outside of the hospital. Such visits 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 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. |
| Physical Therapy | Specialized rehabilitative care, to help restore functions of the body such as walking and the use of arms and legs, usually following an injury or surgical procedure. |
| 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 Offered by Associations or Purchasing Alliances | A health insurance plan that is offered by: (1) business organizations or other professional groups for their members; or (2) through organizations that provide small businesses and sole proprietors a range of choice and greater administrative ease in selecting and purchasing health insurance coverage. For more information, please visit the Association and Purchasing Alliance page. |
| 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 | In New York, a medical condition in which medical advice, diagnosis, care, or treatment was recommended to you or received by you during the 6 month period before the date you enroll in a health plan. Health plans do not have to cover services related to a pre-existing condition for 12 months for both individual and small-group plans. The pre-existing condition waiting period will be reduced or waived if you had prior coverage for the condition and have not had a break in coverage that is longer than 63 days. |
| 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 Note | Please note that some Empire plan premium rates are based on the residence addresses of your employees rather than the office address of your business, so actual premium rates may vary somewhat from those displayed on NYC HI Link. |
| Premium Tier | Health insurance carriers often set up several payment levels for their health plans. Tier 1 can be the cost of one adult. Tier 2 can be the cost of one adult plus a spouse or domestic partner. Tier 3 can be the cost of one adult plus a child or children. Tier 4 can be the cost of families, usually defined as two adults and at least one child. Please note that these tiers and their definitions can vary across health plans. |
| 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. |
| 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. |
| Prescription Drug Deductible | The amount you must pay for prescription drugs before your health plan begins to pay. If this deductible is stated to be an "integrated deductible," then there is not a separate deductible for drug coverage; you must meet the overall plan deductible (i.e. annual deductible) before the plan will start paying toward your prescription drug costs. Similarly, if this deductible is stated to be a certain percentage "after deductible" (such as "100% after deductible"), this means that the plan will cover the stated percentage of your prescription costs after you have met the overall plan deductible. |
| 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. |
| 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. |
| 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. |
| Qualified Health Plans | As part of the determination of eligibility for the Family Health Plus Premium Assistance Program, the Local Department of Social Services reviews whether the health plan includes at minimum: inpatient and outpatient hospital services, physician services, maternity care, preventive health services, diagnostic and x-ray services and emergency services. The benefit plan does not have to include prescription drug coverage. |
| 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. |
| Rider | An agreement that adds services to existing plan coverage for an additional fee to the premium. For instance, many plans offer a rider to extend coverage to unmarried dependent children past 19 years of age. Prescription drug benefits are another common example of a rider. |
| Routine Adult Care | A periodic visit with a provider such as a doctor or nurse practitioner. Some plans offer yearly adult physicals for free. This type of service can also be referred to as preventive care. |
| S-corporation | A corporation in which five or fewer people own at least half the stock and choose to organize as an S-Corporation. It enjoys the legal rights of a corporation but is taxed like a partnership. |
| Schedule C | The U.S. federal income tax form on which profit and loss from an unincorporated business is listed. |
| Section 125 Plan | See "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 50 workers, including owners. These types of businesses qualify for small group insurance, which is often called the “small-group health market.” |
| 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. |
| Sole Proprietor Plan | Health insurance plans available to individuals who are self-employed and do not have any employees. |
| 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. |
| Subscriber | The person responsible for making premium payments or whose employment makes him or her eligible for a health plan. |
| Substance Abuse - Inpatient | Medical treatment for drug or alcohol abuse, detoxification, and rehabilitative services that involves an overnight stay in a clinical or hospital setting. |
| Substance Abuse - Outpatient | Medical treatment for drug or alcohol abuse, detoxification, and rehabilitative services that does not involve an overnight stay in a clinical or hospital setting. |
| Surgical Inpatient Care | Care provided to you after undergoing an inpatient surgery, which helps you recover. |
| Surgical Outpatient Care | Care provided to you after undergoing an outpatient surgery, which helps you recover. |
| Therapy Services - Inpatient | Rehabilitative services, which include physical therapy, speech therapy, and occupational therapy, that are completed during a stay in a hospital. The purpose of these services is to regain function and performance in the part of the body that was injured. |
| Therapy Services - Outpatient | Rehabilitative services, which include physical therapy, speech therapy, and occupation therapy, that are received at a rehabilitation setting at which you do not stay overnight. The purpose of these services is to regain function and performance in the part of the body that was injured. |
| Traditional Health Insurance | See “Fee-For-Service (FFS) Plan” |
| 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-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. |
| Well Child Care | Regularly scheduled health maintenance and preventative care visits designed to help prevent the occurrence of serious disease in children. This may include services such as regular check-ups for adults as well as immunizations, and screenings for appropriate child development for children. |