Here are some common terms you will find in the NYSHIP plan documents and on our web pages.
The enrollee’s share of the cost of covered services, which is a fixed percentage of covered medical expenses.
The enrollee’s share of the cost of covered services, which is a fixed dollar amount paid when a medical service is received, regardless of the total charge for the service.
The dollar amount an enrollee is required to pay before health plan benefits begin to reimburse for services. This amount applies when you use non-network providers.
This is a person who is covered by another person’s plan. It can be a child, spouse or domestic partner.
A method of billing for health care services. A provider charges a fee each time an enrollee receives a service.
A list of preferred drugs used by a health plan. A plan with a closed formulary provides coverage only for drugs that appear on the list. An open or incented formulary encourages use of preferred drugs to non-preferred drugs based on a tiered copayment schedule. In a flexible formulary, brand-name prescription drugs may be assigned to different copayment levels based on value to the plan and clinical judgment. In some cases, drugs may be excluded from coverage under a flexible formulary if a therapeutic equivalent is covered or available as an over-the-counter drug.
Health Benefits Administrator (HBA) - That's us!
An individual responsible for providing benefits assistance to active State employees. HBAs work with the Employee Benefits Division in the Department of Civil Service to process transactions and answer questions regarding eligibility and enrollment. You are responsible for notifying your HBA of changes that affect your enrollment and/or your or your dependents’ eligibility for benefits.
Health Maintenance Organization (HMO)
A managed-care system organized to deliver health care services in a geographic area. An HMO provides a predetermined set of benefits through a network of selected physicians, laboratories and hospitals for a prepaid premium. Except for emergency services and other services approved by your HMO, you and your enrolled dependents may have coverage only for services received from your HMO’s network.
This is the total dollar amount of benefits you can receive. It can also be the total number of services you can receive. These totals are limits for a lifetime, not just for a plan year.
A health care program designed to ensure you receive the highest quality medical care for the lowest cost in the most appropriate health care setting. Most managed-care plans require you to select a primary care physician employed by (or who contracts with) the managed health care system. He or she serves as your health care manager by coordinating virtually all health care services you receive. Your primary care physician provides your routine medical care and refers you to a specialist if necessary.
A group of doctors, hospitals and/or other health care providers who participate in a health plan and agree to follow the plan’s procedures.
New York State Health Insurance Program (NYSHIP)
NYSHIP covers more than 1.2 million public employees, retirees and dependents. It is one of the largest group health insurance programs in the country. The Program provides health care benefits through The Empire Plan and NYSHIP- approved HMOs.
A health insurance plan offered through NYSHIP. Options include The Empire Plan and NYSHIP-approved HMOs within specific geographic areas.
This is a limit on the costs a health plan member must pay for covered services. The limit can be yearly or a dollar amount.
A health insurance plan is primary when it is responsible for paying health benefits claims before any other group health insurance plan. It is important to understand when Medicare will become primary to your NYSHIP coverage. Read plan documents for complete information.
These are events that let members change their health benefits. Examples include death, job loss, divorce and marriage.