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A facility is a hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
FAIR Health, Inc. was established in October 2009 by the office of The Attorney General of the State of New York to help make sure of fairness and transparency in patient reimbursements by providing fee profiles for reimbursement of out-of-network services.
The dollar amount of the member's health benefit coverage that must be met each calendar year before payment can be made on claims. There is a maximum out-of-pocket amount that will satisfy the family deductible. Once that deductible is reached, all claims for the family are then paid at 100% of allowable charges.
A measure the US government uses to decide who needs help paying for health insurance, under health care reform. This figure changes every year and is based on the current cost of living and minimum wage.
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.
The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.
See 'Drug Formulary'.
A dependent enrolled at an accredited institution of learning. The student's principal residence, when not away at school, must be the same as their parents. Upon a member's policy renewal date on or after October 1, 2010, student status will NOT be required for children to remain on their parents' health plan until age 26 (end of birthday month). Dependents do not need to be students, either, to be eligible for coverage under the New York State law. This law enables dependents to be covered until their 30th birthday.
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