Healthfirst Leaf Plans

Glossary of Terms

Qualified Health Plan Glossary

Annual Open Enrollment Period

The period each year during which qualified individuals must choose to keep their existing healthcare plan or enroll in a new healthcare plan in the Exchange. If they do not select a plan during this period, they will not have coverage for the following calendar year.

Open Enrollment for 2015 begins November 15, 2014 and runs through February 15, 2015.

Coinsurance

Your share of the cost of a covered health care service. After you pay your copay, your plan pays a percentage of the remaining cost of medical care. You also pay a percentage of the cost of medical care. An example of a common coinsurance is 20%. In this case, after you pay your copay, Healthfirst will pay 80% of the remaining cost. You will pay 20% of the remaining cost.

Copayment (or copay)

A fixed dollar amount, or a flat fee, that you pay each time you go to the doctor, get a prescription filled, or get other services.

An example of a common copayment is $15 per visit.

Cost sharing

The general term for your expenses (deductibles, coinsurance and copayments). For example, let’s say you have a Healthfirst plan with a deductible of $200, a copay of $15, and a coinsurance amount of 30%. Your copay is $15 every time you visit your doctor. The first time you go to the doctor, the bill (not including the copay) is $200. This means you will pay your deductible of $200 for that first visit. On the second visit, your bill is again $200. This time, since you’ve already paid your deductible, you will pay 30%, or $60, and Healthfirst will pay 70%, or $140.

Covered Service

A service that your plan will pay for if you need it.

Deductible

The amount you must pay each year before Healthfirst pays anything for certain covered services. For example, if your deductible is $500, you need to spend $500 for covered health care services before Healthfirst pays its share. The deductible may not apply to all services. Not all Healthfirst Plans have a deductible. If your plan has a deductible, it will be listed in your Subscriber Contract.

Dependent

An individual who is legally eligible for health plan benefits because of his or her association with a subscriber. Typically, this is a member of the subscriber’s family.

Explanation of Benefits (EOB)

A form that you will receive after a claim has been filed. It explains the treatments that took place, the portion of the cost that is covered under your plan, and the amount left that you may have to pay or may have already paid directly to your provider.

Find out how to read an Explanation of Benefits document by clicking one of the links to the rightEnglish Español 中文

Federal Poverty Level (FPL)

The set minimum amount of gross income that a family (based on family size) needs for food, clothing, transportation, shelter and other necessities as defined by the U.S. Department of Health and Human Services.

Formulary

The list of prescription drugs covered by your plan. This may also be called a Preferred Drug List.

In-Network Provider

The doctors and hospitals that are part of our network. They provide health care to our members. Unless it is an emergency, your Healthfirst Plan only covers health care services from doctors, hospitals and pharmacies that are in our network.

Maximum Out-of-Pocket (MOOP)

The most you have to pay each year for expenses covered by your plan. It’s a sum of the deductible, copay and coinsurance amounts. Once you reach this amount, you do not pay anything for most services. This does not include your monthly premium costs, any charges from out-of-network health care providers, or services that are not covered by the plan.

Network

A group of doctors and hospitals who are contracted to provide health care services to members of a health plan.

Out-of-network Provider

A health care provider (doctor or hospital) that is not a part of a plan network. You will typically pay more if you use a provider that is not in your plan network.

Preauthorization/Precertification

Some health care plans, including Healthfirst, require you to check with them before you get certain services. This is to make sure that these health care services are necessary and are covered before you get them so that you will not be responsible for the entire cost. Preauthorization is required for many services but it is not required in an emergency.

Premium

The amount you have to pay each month for your Healthfirst plan.

Preventative Care Services

Services you receive from your doctor that help prevent disease or to identify disease while it is more easily treatable. Under Health Care Reform, most of these services are 100% covered by your insurance plan, which means that you will not have to pay for them.

Primary Care Physician (PCP)

This is the doctor you go to for most of your health care needs and decisions. Your PCP coordinates most of your care, authorizes treatment, and may refer you to specialists. Your PCP may be a general internist, family practitioner, OB/GYN, Certified Nurse Practitioner, physician’s assistant, or pediatrician.

Qualified/Qualifying Life Event (QLE)

If you experience a Qualifying Life Event (QLE), you will be able to enroll in a new health plan. Life Qualifying Events include:

 

  • Birth of a child
  • Loss of employment
  • Marriage
  • Change in legal status (divorce, legal separation, marriage, annulment)
  • A change in the number of dependents (birth, death, adoption)
  • Change in employment status
  • Loss of coverage
  • Change in place of residence

*Must apply within 60 days of event

Subsidy

Monetary assistance to help pay health insurance expenses, provided in the form of a refundable tax credit.