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Get help with COVID testing, treatment, and bills. Call CHA (888) 614-5400.

CHA can help answer your healthcare questions.

  • Call our helpline at (888) 614-5400 Monday to Friday, 9am to 4pm,
  • or email cha@cssny.org.

Key Terms

Here are some key terms related to health insurance. Understanding these terms will help you understand how to use your coverage.

  • Allowed Amount – The maximum amount that a plan will pay for a service. For in-network providers, the allowed amount is negotiated between the plan and its providers.
  • Appeal – A request for your health plan to review a previous decision or grievance.
  • Appeal Agent – an independent medical review organization whose doctors decide whether the plan’s decision was correct or should be overturned based on the enrollee’s medical records and standard medical practice.
  • Balance Billing – When your plan pays a provider a set amount for a service, and then the provider charges you for the remainder of what they charge for a service.
  • Co-insurance – A set percentage of the cost of covered health service, which you must pay.  Co-insurance varies for different services and are usually paid when the service is received.
  • Co-payment or “co-pay” – A fixed amount you pay for a covered health care service to a health care provider. Co-pays vary for different services and are usually paid when the service is received.
  • Cost Sharing – The amount of money that you must pay out of your own pocket for health care services. Some examples of cost sharing are co-pays, co-insurance and deductible.
  • Deductible – The amount you must pay for services before your health care plan begins to cover services.
  • Explanation of Benefits (EOB) – For each claim made to your health plan on your behalf, you receive an EOB which explains how the claim was processed, including: what your insurance paid your provider; what you must pay, and why. This is not a bill.
  • External Appeal – An appeal to the New York State Department of Financial Services (DFS) after an enrollee’s plan issues a final denial for health care services as not medically necessary, experimental/investigational or as an out-of-network referral/service
  • Formulary – A list of prescription drugs covered by an insurance plan. Also called a drug list.
  • Fully-Insured – A health insurance plan that is governed by state laws.
  • Grievance – A complaint that you make to your health plan about the plan’s services or benefits.
  • Independent Dispute Resolution – This is a process that determines whether or not the provider charges are reasonable according to what other providers in your area charge for the same service.
  • Maximum Out-of-Pocket (MOOP) – The most you pay during an annual health insurance policy period before your health plan begins to pay 100% of covered services.
  • Open Enrollment Period – Annual date range when an enrollee or employee must enroll in a health insurance plan for active coverage the following plan year.
  • Out-of-Pocket Costs – Costs that you must pay your provider. These can include deductibles, coinsurance, and copayments, or similar charges, but do not include premiums, balance billing amounts for out-of-network providers, or the cost of non-covered services.
  • Preauthorization / Prior Approval – An enrollee or provider’s request that your plan cover a service as medically necessary. Your plan may require that you request prior authorization before certain services are covered as part of their utilization review process.
  • Preferred or In-network Provider – A physician or other provider who is contracted with your health insurance plan and in your health plan’s network.  Seeing a preferred provider often reduces your out-of-pocket costs.
  • Premium – The monthly amount that you pay to keep your health insurance active.
  • Preventive Health Services – All plans must cover a specific set of preventive services, such as vaccinations and screenings, when given by an in-network provider.  There is no cost sharing for preventive services, which do not include wellness visits or annual check-ups.
  • Provider Network – The hospitals, facilities, physicians, and other health care providers who contract with your health plan to provide care.
  • Referral – A written order from your primary care physician giving you permission to see a specialist or get certain medical services. Many health plans require a referral before you can get medical care from anyone except your primary care physician. In these plans, if you don’t get a referral first, the plan may not pay for the services.
  • Self-insured – A health plan contracted by your employer or union, governed by federal laws only.
  • Summary of Benefits and Coverage (SBC) – An overview of the plan’s covered benefits, cost-sharing provisions, and coverage limitations and exceptions. You should get an SBC from your plan when you enroll.
  • Utilization review – A process in which a managed care plan decides if an enrollee should get health care that their doctor has requested, or if the plan should pay for care that the enrollee has already received.  Utilization review decisions should be made by doctors that work for the plan.

CHA can help answer your healthcare questions.

  • Call our helpline at (888) 614-5400 Monday to Friday, 9am to 4pm,
  • or email cha@cssny.org.

Healthcare Q&A

Read short articles that answer frequently asked questions about healthcare and insurance. Find out how CHA has helped others, and can help you. Choose a topic: