Glossary of Key Terms

Below is a glossary of health care terms to help navigate information on the NYCE PPO plan:

ACA/NYS drugs: Medications that are mandated by either the Affordable Care Act or New York State law and are covered by city health insurance coverage (e.g., birth control, PrEP and diabetes medications), not by another program that provides a prescription drug benefit such as the UFT Welfare Fund. These drugs are now distributed through Express Scripts but will be distributed through Prime Therapeutics under the new plan.
AdvantageCare Physicians (ACPNY): EmblemHealth's primary and specialty care practice for patients in New York City and Long Island.
Center of Excellence: A health care institution that specializes in one area and provides expert levels of care, such as Memorial Sloan Kettering Cancer Center and the Hospital for Special Surgery.
Copay: A fixed amount paid by a member for receiving a particular health care service, with the remaining balance usually covered by the person's insurance company.
Coinsurance: The amount a member pays for health care services after meeting their deductible. If a member has 20% coinsurance, they are responsible for 20% of the cost of each service, while their insurance company is responsible for 80% of the cost.
Example: You have met your deductible and a doctor's visit costs $100. You will have to pay $20 if you have 20% coinsurance.
Deductible: A fixed amount a member must pay during a given time period, usually a year, before their health insurance benefits begin to cover the costs.
Downstate 13 (DS13): The 13 Downstate counties of New York that make up EmblemHealth’s coverage area in the new plan. They are: New York City (five boroughs), Long Island (two counties), and Dutchess, Orange, Putnam, Rockland, Ulster and Westchester counties.
Durable medical equipment (DME): Medically necessary equipment for sick, disabled or injured people, including items such as wheelchairs, walkers, CPAP machines and oxygen equipment. Under the NYCE PPO plan, these items are still be subject to a $100 deductible that is reimbursed by the UFT Welfare Fund for Welfare Fund-eligible members.
EmblemHealth: EmblemHealth is an insurance company that will provide medical and hospital coverage in the Downstate 13 counties under the NYCE PPO. It is currently our medical provider in the GHI CBP plan.
Express Scripts (ESI): Express Scripts is a pharmacy benefits manager that provides prescription drugs for the UFT Welfare Fund and the NYC PICA Program. It will continue to be the pharmacy manager for both.
Hospital for Special Surgery (HSS): This hospital is a Center of Excellence in New York City that specializes in orthopedic surgeries. HSS will remain in-network in the new plan, and HSS Perform, the concierge service for UFT Welfare Fund-eligible members in partnership with the UFT Welfare Fund, will remain in place.
NYC Health and Hospitals (H+H): NYC’s municipal system of hospitals and providers. This system will be added as a preferred provider in the new plan and offer more options for copay-free care.
In-network providers: When a doctor, hospital or other health care professional accepts your health insurance plan, they are in-network providers.
In-network preferred providers: In the NYCE PPO plan, AdvantageCare Physicians and H+H are in-network preferred providers. For most services, there are no copays when using these preferred providers.
In-patient services: Care provided at a hospital or a facility where you stay overnight.
In-service employee: A New York City employee who is actively working and not retired.
Memorial Sloan Kettering (MSK): This hospital is a Center of Excellence in New York City that specializes in cancer care. MSK will remain in-network in the new plan, and MSK Direct, the concierge service for UFT Welfare Fund-eligible members in partnership with the UFT Welfare Fund, will remain in place.
Municipal Labor Committee (MLC): The MLC is an umbrella coalition of municipal labor unions across New York City, including the UFT. With input from these unions, the MLC negotiates health care for all city workers and retired city workers.
Negotiated acquisition: A negotiated acquisition is like a request for proposals (RFP) — a formal process that the city uses to select a vendor or contractor — but it is less rigid. Negotiated acquisition allows the city and the MLC to go back and forth with a bidder and tell them to do better.
Out of network: When you go to a doctor or health care professional who doesn't take your insurance plan, they are an out-of-network provider.
Out-of-pocket maximum: The maximum amount you will be required to pay for health care before your health insurance covers 100% of the costs.
Outpatient services: Services provided where you do not have to remain in a facility overnight. Outpatient services can be performed in doctor's offices, hospitals, surgery centers and other locations.
PICA: PICA is a prescription drug benefit program administered by Express Scripts that covers most self-injectable medications and chemotherapy medications. PICA prescriptions will not be affected by the new plan.
Preferred provider organization (PPO): A health insurance plan that offers the flexibility to see an in-network provider with a defined copay or to see an out-of-network provider and seek reimbursement according to a scheduled allowance.
Pre-Medicare-eligible retiree: City retirees who are younger than 65 and not yet eligible to receive Medicare benefits. They are enrolled in the same city health plans as in-service employees.
Premium-free health care: New York City municipal workers do not have to pay a monthly fee (or a premium) for basic-level health care because the city pays that amount for them. This is part of the health care package that the MLC negotiated for us.
Prime Therapeutics: Prime Therapeutics is a pharmacy benefit manager that will provide prescription drugs for the NYCE PPO. It will replace Express Scripts for any prescription drugs under the new plan such as pre-Medicare-eligible retirees’ optional rider and any in-service drugs covered under the Affordable Care Act or New York State law. This company is not Amazon Prime.
Prior authorization: When a health care provider like a doctor or hospital must get prior approval from the health plan before prescribing a medication, running a diagnostic test or doing a medical procedure.
Providers: A provider refers to any licensed medical professional from whom people may receive billable services. This term can include, but is not limited to, doctors, physical therapists, occupational therapists, lab technicians, physician’s assistants and nurse practitioners.
PT/OT/ST: These are acronyms for physical therapy, occupational therapy and speech therapy.
UnitedHealthcare (UHC): UnitedHealthcare is a health insurance company that will provide medical and hospital coverage outside the Downstate 13 counties and nationwide. This coverage will vastly expand the network by 1.6 million providers.