Definitive Guide

Understanding Health Insurance Terms for New Yorkers

Health insurance can be confusing! One of the main reasons is the terminology.

They’re often confusing and a little intimidating, too—even for notoriously tough New Yorkers!

“The health insurance landscape is filled with jargon and acronyms,” says MetroPlusHealth’s Chief Information Officer, Ganesh Ramratan. “We’re here to help and just a visit or a phone call away, but New Yorkers are busy.”

“The health insurance landscape is filled with jargon and acronyms. We’re here to help and just a visit or a phone call away, but New Yorkers are busy.”

Ganesh Ramratan

MetroPlusHealth’s Chief Information Officer

From finding alternate side parking schedules to picking the best subway car for the quickest exit, you have other things to do besides research health insurance terms.

That’s why we’ve compiled this guide to understanding health insurance terms for New Yorkers. We hope it helps demystify some of the most common terms you’ll come across. To help make it easy, we’ve broken it into three sections:

Payment terms
Coverage terms
Eligibility terms

Understanding payment terms

One of the most important features of a health insurance plan is its cost. When comparing plans, the amount you’ll have to pay for coverage is perhaps the most important factor.

Here’s a guide to common health insurance payment terms:

Deductible: The amount of money you’ll have to pay out of pocket for health care services before your insurance starts paying. At the beginning of each year, your deductible starts over at zero.
Copayment: The fixed amount of money you have to pay for certain health care services. As healthinsurance.org notes, copayment is often shortened to “copay”. Copays can apply to everything from doctor visits to prescriptions. Sometimes they depend on meeting your deductible, sometimes they apply regardless of the deductible.
In-network: Health care providers who have agreed to accept your insurance plan, usually at a discounted rate. Using in-network providers often means cost savings for both you and your insurance company.
Out-of-network: A provider or facility that takes your insurance, but doesn’t have an in-network agreement in place. You can use out-of-network providers, but it’s likely going to mean a higher bill and that the services you receive won’t apply toward your deductible.
Out-of-pocket maximum: The most you have to pay for covered, in-network services in a single plan year. HealthCare.gov explains that there are a few things not included in an out-of-pocket maximum like monthly premiums, out-of-network services, services not covered by your plan, and costs above the “allowed amount for a service” that a provider might charge.
Claims: Requests made to a health insurance company to pay for services received. Often the providers you see will submit a claim on your behalf, especially if they’re in-network. You can also submit claims directly, and often will have to for out-of-network services.

Understanding coverage terms

The next batch of health insurance terms to understand are coverage terms. Coverage terms are the words that health insurance companies use to describe the services they do and don’t cover.

As you research different health insurance plans, you might find yourself confused and wondering things like, what’s the difference between HMO, PPO, and EPO? What does PCP mean? What’s included in vision coverage anyway?

Let us help explain:

HMO stands for health maintenance organization, a type of insurance plan that usually limits coverage to services from doctors included in the HMO. This often means the plan won’t cover any portion of services from a provider that’s not in the HMO.
PPO stands for preferred provider organization, a plan that charges less for services from in-network providers. Usually you can still see out-of-network providers with a referral, but often at an additional cost.
EPO stands for exclusive provider organization, a plan where only services from in-network doctors, specialists, and hospitals are covered. Emergencies are an exception.
PCP stands for primary care provider, the person who is your main medical provider. Your PCP is the doctor you see for preventative care, common health issues, and referrals to specialists, explains Verywell Health. Many insurance providers offer ways for you to search their in-network providers, like our Provider Search does.

The difference between emergency room and urgent care

When a health need comes up that can’t wait for an appointment, the two main options are urgent care or emergency room care.

Urgent care centers are “the middle ground” between your regular doctor and emergency room care, according to the Mayo Clinic. If you have an acute but not serious or life-threatening issue, urgent care is the way to go.

The emergency room is where you can get immediate care for serious health issues like head injuries, severe abdominal pain, uncontrolled bleeding, and more.

Urgent care clinics have hours that extend beyond most doctor’s offices, but they still close. Emergency rooms are open 24/7.

What’s included in vision coverage

Each vision plan is different, but generally vision plans will cover:

Annual vision exams
Contact lenses
Eyeglass frames and lenses

Qualifying for $0 health care: Understanding eligibility terms

There’s one more set of terminology to understand: Eligibility terms.

Many states have free and low-cost health insurance plans for individuals and families who qualify. In New York, two of the most common $0 or low-cost plans are the Essential Plan and Child Health Plus.

Here are the common eligibility-related terms you’ll come across:

Income-qualified: This means that you or your family meet the income limits established to qualify for free or low-cost health insurance programs.
Household or family size: The number of people living in your home. This number is used to help determine whether or not you meet the income limits.
Household or family income: The amount of money your family earns each year or each month. This is the second factor used to determine whether or not a person or family qualifies for a state health insurance program by meeting income limits.

These are common eligibility terms, but not the only ones. “Free or low-cost programs usually have several eligibility requirements. One of the best ways to figure out if you qualify for a $0 health care plan is to apply,” says Dr. Talya Schwartz, President and CEO of MetroPlusHealth.

“Free or low-cost programs usually have several eligibility requirements. One of the best ways to figure out if you qualify for a $0 health care plan is to apply.”

Dr. Talya Schwartz

President and CEO of MetroPlusHealth

What if I still have questions?

We hope this crash course in some of the most common health insurance terms helps. But it’s not a substitute for reading a plan’s fine print or getting questions answered by knowledgeable staff like the MetroPlusHealth team.

If you have questions about confusing terminology or qualifying for a $0 health care plan, we’re always here to help. Give our Member Service Center a call at (855) 809-4073. You can also get help in person at one of our many offices throughout the city’s five boroughs.

Not only can we answer your questions, but we can help walk you through application processes, too!