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Using This Guide > How Do HMOs Work? | How To Choose An HMO | Terms You Should Know | Data Sources | Types of Complaints | Crosswalk of Health Insurer Names | Worksheet to choose an HMO

Terms You Should Know

Health Insurance Terms Used in this Interactive Guide

Co-Insurance: Some insurance coverage requires you to pay a percentage of the cost of covered medical services, usually 20 percent-30 percent of the allowed amount. For example, you pay 20 percent of the allowed amount, and your insurance pays 80 percent of the allowed amount. Your portion of the allowed amount is the co-insurance.

Commercial Insurers: Health insurance can also be written by other types of insurers such as life insurers and property/casualty insurers. These insurers offer products similar to those provided by non-profit indemnity insurers. (See Nonprofit Indemnity Insurers) Benefits are subject to deductibles and significant out-of-pocket costs unless members use a preferred provider network.

Complaint: When a consumer or provider complains to the State of New York about a health insurer.

Copayment: A flat fee for specified medical services required by some insurers. For example, you pay a $20 copayment for a doctor visit, or a $50 copayment for a hospital stay.

Deductible: The amount members must pay each year for medical expenses before their insurance policy starts paying. Deductibles are common in FFS plans and PPOs.

Experimental/Investigational: Services that your health insurer or HMO have determined are either unproven for the diagnosis or treatment of your condition or not generally recognized by the medical community as effective or appropriate for the diagnosis or treatment of your condition.

External Appeal: A review of a denial of health care services the health insurer considers to experimental, investigational or not medically necessary. The review is conducted by an external review organization not affiliated with the health insurer or the member's doctor or family.

Fee-for-Service (FFS): Also known as indemnity insurance, FFS is a type of health coverage in which members may go to any doctor or provider. The health insurer reimburses for each covered service provided. Deductibles and co-insurance usually apply in FFS coverage.

First-level Internal Appeal Process: The process of appealing medical necessity, experimental and investigational denials through your health insurer. If the appeal is not decided in your favor, you are entitled to request an external review. (See External Appeal)

Grievance: When a member or provider complains to a health insurer about denials based on limitations or exclusions in the contract.

Health Maintenance Organization (HMO) Plan: A type of managed care coverage in which members receive comprehensive health services in return for a monthly premium and copayment. Members are assigned to a PCP who coordinates their care and refers patients to specialists and provider services, as needed. Although many HMOs require members to see doctors and other providers in the HMO provider network, some offer members the option to go out of network (POS plans, for example). HMO plans often require members to get a PCP referral before seeing a specialist. (See Primary Care Physician and Point of Service Plan)

Internal Appeal or Utilization Review (UR): When a consumer asks a health insurer to reconsider its refusal to pay for a medical service it considers experimental, investigational or not medically necessary. (See First-Level Internal Appeal Process.)


State of New York
David A. Paterson
State of New York
Department of Insurance
Eric R. Dinallo
Superintendent of Insurance
State of New York
Department of Health
Richard F. Daines, M.D.
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