Navigate your insurance coverage with ease.
IMPORTANT EVENTS
Open Enrollment
Annual period where individuals and employees are able to choose or make changes to their health plan.
Special Enrollment
A Special Enrollment Period is when someone has a special life event (called a “Qualifying Life Event”) that makes it possible for them to enroll in or change their coverage through a Qualified Health Plan outside of the Open Enrollment Period.
What Qualifying Life Events might make someone eligible for a Special Enrollment Period?
- Qualifying Life Events include:
- Loss of health insurance (for reasons other than you did not pay your premium)
- A permanent move into New York State or a move within the State that makes new health plans available to you (you must have had other coverage within the past 60 days)
- Marriage or domestic partnership (you must have had other
coverage within the past 60 days) - Divorce or legal separation
- Pregnancy certified by a health care practitioner
- Birth or adoption of a child, or placement of a child in foster care
- Becoming eligible or ineligible for help paying for your Qualified
- Health Plan coverage
- Becoming a citizen, national or lawfully present individual
Generally, you must report a Qualifying Life Event to NY State of Health within 60 days. You may need to provide proof of the Qualifying Life Event to your new health plan or to NY State of Health.
PROVIDER AND PLAN TYPES
In-Network
Healthcare provider is contracted with the insurance company, agrees to charge the client according to their benefits, and will be reimbursed according to the agreed upon allowance.
Out-of-Network
Provider is not contracted with the insurance companies and can charge the full rate.Client’s benefits aren’t guaranteed.
Individual Plans
Purchased directly from the insurance marketplace and payments are made to the insurance company.
Employer-Sponsored Plans
Enrolled in with your or a family member’s employer.
INVOLVED PARTIES
Policy Holder
Employee/person responsible for enrolling in plan.
Dependent
Family member of policy holder (spouse, child, etc).
Payer
Common term for insurance companies.
PAYMENT TYPES
Allowance
How much a payer agrees to cover of the total cost of care.
Write-off
Difference between the total cost of care and the allowance.
Copay
Fixed amount paid by the client directly to the healthcare provider.
Deductible
Specific amount of money the client must pay before insurance covers any of the cost
Coinsurance
Percentage of allowance that the client pays to the healthcare provider. For example, client owes 20% and insurance covers the other 80%.
Health Savings Account (HSA)
Like a debit card with pre-taxed earnings to go towards qualifying care-related expenses.
Flexible Spending Account (FSA)
Like an HSA but owned by client’s employer.
Health Reimbursement Account (HRA)
Account contributed to by the policy holder’s employer to help offset healthcare expenses. Generally integrated with the insurer.
