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 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.

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.

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

• Annual vision exams
• Contact lenses
• Eyeglass frames and lenses

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.

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!