Get to Know Health Care


The health care items or services covered under a health insurance plan.

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. The health insurance or plan pays the rest of the allowed amount.

An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage.

Cost Sharing
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHP also includes premiums.

Covered Services
The general term used to mean all of the health care services and supplies that are covered by our plan.

The amount of expenses that must be paid by you before an insurer will pay any expenses. The deductible applies before any coinsurance or copayments are applied.

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Open Enrollment Period  
The period of time during which individuals who are eligible to enroll, can enroll in a plan. For example, to enroll for 2017 coverage in the NY State of Health Marketplace, the Open Enrollment Period is November 1, 2016 – January 31, 2017. 

Out-of-Network Provider or Out-of-Network Facility
A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of network providers are providers that are not employed, owned, or operated by our plan or are not under contract to deliver covered services to you.

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Primary Care Provider (PCP)
Your primary care provider is the doctor or other provider you see first for most health problems. He or she makes sure you get the care you need to keep you healthy. He or she also may talk with other doctors and health care providers about your care and refer you to them.