Glossary of health coverage and billing terms
Deductible, coinsurance, MAGI, chargemaster, prior authorization — the vocabulary of American health coverage, explained with New York specifics.
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.
Federal poverty level (FPL)
A federal income benchmark, updated each January, that decides eligibility for most health programs in New York.
Deductible
The amount you pay yourself each year before the insurance plan starts paying its share.
Copay
A fixed amount you pay for a specific service — $25 for a visit, $10 for a generic drug.
Coinsurance
Your percentage share of a bill after the deductible — 20% of a $4,000 procedure is $800.
Out-of-pocket maximum
The annual ceiling on what you pay for in-network covered care. After it, the plan pays 100%.
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
The list of drugs a plan covers, sorted into tiers that determine what you pay.
Prior authorization
Approval the insurer requires before it will pay for a service — and a common reason care gets delayed.
Explanation of benefits (EOB)
The statement from your insurer showing what was billed, what was paid, and what you may owe. It is not a bill.
Chargemaster
A hospital's internal list price for every service. Almost nobody pays it — except the uninsured who don't ask.
Charity care
The hospital financial assistance every New York hospital is legally required to run.
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)
The income definition New York uses to decide Medicaid, Essential Plan and subsidy eligibility.
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 charge set by your income rather than a fixed price list. The standard at community health centers.
Good faith estimate
A written cost estimate uninsured and self-pay patients are entitled to before scheduled care.
Balance billing
When a provider bills you for the gap between its charge and what your plan paid.