The words on an insurance card and the words on a hospital bill are the same industry vocabulary, and almost none of it is defined where you first meet it. This glossary defines the terms as they actually work in New York — which threshold, which program, which law.
Each entry is short by design. Where a term connects to something that changes what you pay, the entry links to the guide that covers it.
How to use this glossary
Look the word up when it appears on a document you are holding, not before. Each entry answers three things in order: what the word means in plain terms, what it means in New York specifically, and which page explains the decision it belongs to.
The New York part is the reason this glossary exists. A national definition of “deductible” is easy to find and tells a New Yorker nothing about the fact that the Essential Plan has none, or that a high deductible can make you legally underinsured and cap what a hospital may charge you. The same is true of nearly every term below.
The words that cost people the most money
Chargemaster — the number printed on an uninsured patient’s bill, which almost nobody pays and which state law caps.
Explanation of benefits — the document that looks like a bill, is not a bill, and settles arguments about bills.
Balance billing — being charged the gap between a provider’s charge and what the plan paid, which is prohibited in the situations where you had no realistic choice.
Coinsurance — a percentage of the plan’s allowed amount, never of the charge, and that distinction is the whole argument on a disputed bill.
MAGI — the income definition every program uses, which is not your salary and which pre-tax contributions legitimately reduce.
Federal poverty level — the number every New York threshold is a multiple of, republished each January.
Where the words come from
Insurance vocabulary is written by the industry that bills you, which is why so much of it is defined nowhere you would meet it. We define terms as they behave in New York, cite the primary source, and date the check. Where a term connects to a decision that changes what you pay, the entry links to the guide rather than repeating it.
In this section
Federal poverty level (FPL)
The federal poverty level is the annual income figure New York health programs are measured against. The 2026 amounts and every state threshold built on them.
Deductible
A deductible is what you pay for covered care each plan year before your plan pays its share. How it works, what skips it, and which New York plans have none.
Copay
A copay is a fixed amount you pay for a covered service. How it differs from coinsurance, when the deductible comes first, and the copay rules New York adds.
Coinsurance
Your percentage share of a bill after the deductible — 20% of a $4,000 procedure is $800.
Out-of-pocket maximum
The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
Network (in-network and out-of-network)
The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.
Formulary
A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
Prior authorization
Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
Explanation of benefits (EOB)
An explanation of benefits (EOB) is your plan's record of a claim, not a bill. How to read each line, which one a bill must match, and what a denial means.
Chargemaster
A hospital's internal list price for every service. Almost nobody pays it — except the uninsured who don't ask.
Charity care
Charity care is the everyday name for hospital financial assistance in New York. Who qualifies, the income tiers to 400% of poverty, and how to apply.
EMTALA
The federal law requiring emergency rooms to screen and stabilize anyone, regardless of insurance or status.
Special enrollment period
A window outside open enrollment when a life event lets you sign up for a marketplace plan.
MAGI (modified adjusted gross income)
MAGI, modified adjusted gross income, decides Medicaid, Essential Plan and marketplace eligibility and adjusts Medicare premiums. What counts, which year.
Premium
What you pay monthly to have coverage, separate from what you pay when you use it.
Metal tiers (bronze, silver, gold, platinum)
How marketplace plans are labeled by what share of costs the plan carries, not by quality of care.
Navigator
A certified, free helper who walks you through enrollment and earns no commission on your choice.
Sliding scale fee
A sliding scale fee is a price set by household income and size. How the scales at NYC community health centers and NYC Care work, and what to bring.
Good faith estimate
A good faith estimate is the written cost estimate uninsured and self-pay patients are owed before scheduled care. What it must list, and the $400 rule.
Balance billing
Balance billing is a provider billing you the gap between its charge and your plan's allowed amount. When New York bars it, including Medicare's 5% cap.
CDPAP (Consumer Directed Personal Assistance Program)
The New York Medicaid program that lets a person hire, train and supervise their own home care aide, including a relative.
Spend-down (excess income)
The monthly amount of medical expense you must incur before Medicaid covers the rest of the month, when your income is over the limit.
Pooled income trust
A trust run by a nonprofit that holds your excess monthly income so Medicaid disregards it, while still paying your rent and bills.
Fair hearing
The state's review of a decision about your Medicaid, with two different deadlines that people routinely confuse.
Managed Long Term Care (MLTC)
The plan that authorizes and pays for long-term home care in New York. It is the payer, not the care itself.
Dual eligible
Having Medicare and Medicaid at the same time, which covers premiums, cost sharing and the long-term care Medicare does not.
Parity (mental health parity)
The rule that a health plan may not make mental health and substance use care harder or costlier to get than comparable medical care.
Step therapy
The rule that you must try a cheaper drug first before the plan will cover the one you were prescribed.
Ground ambulance
The one emergency service the federal surprise billing law left out, which is why a bill can still arrive for a ride you did not choose.
HARP (Health and Recovery Plan)
A type of New York Medicaid managed care plan for adults with serious behavioral health needs, which the state enrolls you into rather than you applying.
Facility fee
A charge for the place rather than the care, billed when a site is licensed as part of a hospital, even when it looks like an ordinary office.
CPT code
The five-character code for a specific medical service. Without it, every price you are quoted is about something slightly different.
Preventive care
The category of services a plan must cover with no cost sharing, and the reason a 'free' screening sometimes arrives with a bill.
Medically necessary
The phrase that decides almost every denial, and the standard you argue against when a plan says no.
Out of network
A provider with no contract with your plan, which changes what you pay and, in some situations, whether you can be billed for the difference at all.
Superbill
An itemised receipt with diagnosis and procedure codes that you submit to your own plan for out-of-network reimbursement.
Premium tax credit
The subsidy that lowers a marketplace premium, paid in advance to the insurer and reconciled on your tax return.
Qualifying life event
The change that opens a 60-day window to enrol outside the marketplace season, and the clock that starts the day it happens.
Essential health benefits
The ten categories every marketplace and small group plan must cover, and the reason a plan that skips one is not really insurance.
Presumptive eligibility
A temporary approval that starts care immediately while a full Medicaid application is processed, and the one thing it does not carry.
Annual maximum
A dental plan's ceiling on what the plan pays in a year, which is the opposite of a medical out-of-pocket maximum despite the similar name.
Federally qualified health center
A clinic required to charge by household income rather than by service, which is why it is the cheapest real option for most uninsured New Yorkers.
Managed care
A plan that pays a private insurer a fixed amount per member to run your benefits, which is why a network and prior authorization exist at all.
Cost-sharing reduction
A discount on the deductible and copays that only attaches to silver marketplace plans, and is invisible when you compare premiums.
Underinsured
Having coverage and still being unable to afford care, which in New York is not just a description but a legal category with a threshold.
Open enrollment
The annual window for buying or changing a marketplace plan, and the three programs in New York that ignore it entirely.
Grievance
A complaint about how a plan behaved, which is a different process from an appeal about what it decided, and people file the wrong one constantly.
Self-funded plan
An employer plan where the company pays claims from its own money, which puts it under federal law and outside New York's protections.
Network adequacy
The requirement that a plan's network actually produce appointments, which is what makes an unreachable directory a violation rather than bad luck.
Primary service area
The geography that decides whether a hospital owes you financial assistance for non-emergency care, and the one situation where a refusal can be legitimate.
Emergency Medicaid
Coverage for the treatment of an emergency medical condition, including childbirth, for people who meet Medicaid's income rules but not its immigration rules.
External appeal
The review of a denial by someone who does not work for your insurer, taken after the plan's own internal appeal, and the step most people stop short of.
Utilization review
How a plan decides whether care it would otherwise cover is medically necessary — before it happens, while it happens, or after the bill already exists.
Aid to continue
The request that keeps a benefit running unchanged while an appeal is decided — a separate ask from the appeal itself, and the one people forget to make.
Workers' compensation
Not health insurance but a separate system that pays the whole cost of treating a work injury, which is why one sentence at the registration desk decides the bill.
Allowed amount
The number a plan treats as the price of a service, which is almost never the number on the bill and is what your percentage share is actually taken from.
Tax household
The group whose income is counted together for coverage eligibility, decided by who files a tax return with whom rather than by who lives in the apartment.
Qualified health plan
A plan certified for sale on a health insurance marketplace, which guarantees a floor of benefits and protections and tells you nothing about the network.
Limited English proficiency
The administrative status that triggers free language help in health care, which describes an encounter rather than passing judgment on a person.
Qualified interpreter
The federal standard for who may interpret in a medical conversation, which rules out a bilingual colleague, a relative, and anyone you cannot follow.
More in Glossary of health coverage and billing terms
- Copay — A copay is a fixed amount you pay for a covered service. How it differs from coinsurance, when the deductible comes first, and the copay rules New York adds.
- Coinsurance — Your percentage share of a bill after the deductible — 20% of a $4,000 procedure is $800.
- Out-of-pocket maximum — The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
This page explains how the system works. It is not medical advice. More.