Health plan basics

We can’t make healthcare less complex, but we can try to make it easier to understand. Below you will find some definitions and explanations of common terms you’ll find in our plans.



Provider networks

The best way to maximize the benefits of your health plan is by choosing a participating in-network provider for your covered health care services. Our Individual and Family plans do not have coverage for out-of-network providers except for emergency and urgent care services.

We offer three provider networks:



See if your doctor is an in-network provider 




Preventive care coverage

We believe the best way to keep our community healthy is through robust preventive care options.

All our plans cover certain preventive care in full* prior to meeting your deductible, including:


  • Well baby care (from any provider licensed to provide this service)
  • Periodic health examinations (from any provider licensed to provide this service)
  • Routine immunizations and shots
  • Annual women’s gynecological exams
  • Mammograms
  • Colorectal cancer screening exams (preventive age 50 and over)
  • Pediatric routine eye exams (one per calendar year)




Deductibles

Your plan’s annual deductible is the amount you pay for covered services before your plan kicks in to pay for those services. A new deductible occurs every calendar year.

Deciding what type of deductible you want often comes down to how often you plan on using certain covered services. If you find yourself frequently using services, a lower deductible may save you money. If you don’t typically use services very often, a higher deductible may be the more cost-effective choice for you.

Higher deductible plans have lower monthly costs, but you’ll pay more for certain covered services before your plan will begin to pay.

Lower deductible plans have a higher monthly costs and require you to pay less for certain covered services before the plan begins to pay.




Creditable coverage

Coverage is creditable when the plan payout for prescription drugs is, on average for all plan participants, as much as the average payout under the standard Medicare Part D benefit.

Coverage is non-creditable when the plan payout for prescription drugs is, on average for all plan participants, less than what standard Medicare Part D prescription drug coverage would be expected to pay.


Oregon creditable coverage

Washington creditable coverage




Copayment and coinsurance

Once you’ve met your annual deductible, you share the costs of covered health services with your health plan through copayments and coinsurance.

  • Copayment is a fixed amount you pay for a covered service at the time care is provided. For example, if your copay is $20 for an office visit, you pay $20 at the time of your visit.
  • Coinsurance is a percentage of cost you pay for a covered services. For example, if your coinsurance rate is 20 percent and a health care service costs $125, you pay only $25 (20 percent of $125).



Out-of-pocket maximum

We want to protect all our members from the catastrophic costs that may come from a serious injury or health conditions (even with covered services). To do this, we set annual out-of-pocket maximum costs for covered services. This amount includes your deductible.

Once you’ve met your out-of-pocket maximum, your plan will cover 100 percent of covered services for the remainder of the calendar year.

Your maximum out-of-pocket cost and the services that do not apply to the out-of-pocket maximum vary by plan.




Health insurance glossary

Dive further into common health insurance terms that may still be confusing in our health plan glossary.

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