Health Plan Glossary


  1. A

    1. Accidental injury:

      An injury that is due directly to an unintentional act, independent of all other causes.

  2. C

    1. Calendar year:

      A 12-month time period beginning January 1ˢᵗ and ending December 31ˢᵗ.

    2. Coinsurance:

      A percentage of the dollar amount that you are responsible to pay to a healthcare provider, after your claim has been processed by us. Your coinsurance for a covered service is shown in the benefit summary, and is a percentage of the charges for the covered service. For example, if a healthcare service is covered at a 20 percent coinsurance, you would pay 20 percent of the covered costs, and the plan would pay 80 percent.

    3. Copay:

      The dollar amount that you are responsible for paying to a healthcare provider when you receive certain covered services, as shown in the benefit summary. For example, if an office visit is covered at a $20 copay, you would pay $20, and the plan would pay the remaining covered costs.

  3. D

    1. Deductible:

      The dollar amount that you are responsible to pay every calendar year for covered services before your plan will begin to pay for these services. 

    2. Dependent:

      The policyholder's spouse, domestic partner, or eligible family member.

    3. Domestic Partner:

      Oregon residents
      At least 18 years of age, has entered into a domestic partnership, and has legally registered a Declaration of Domestic Partnership and obtained a Certificate of Registered Domestic Partnership in accordance with Oregon state law.

      Washington residents
      "State registered domestic partners” means two adults who meet the requirements for a valid state registered domestic partnership as established by RCW 26.60.030, and who have been issued a certificate of state registered domestic partnership by the secretary.

  4. E

    1. Effective date of coverage:

      The date upon which coverage begins.

    2. Exclusion:

      A service or supply not covered by the health plan.

  5. L

    1. Limitations:

      Coverage is limited by quantity, frequency, provider or type of service.

  6. M

    1. Marketplace:

      Also called an “exchange,” a health insurance marketplace is a place where you can buy health coverage online.

    2. Medical Home:

      A cooperative, patient-centered clinic made up of providers and staff who work with you to address your physical and behavioral health needs and goals. Not all in-network providers and facilities are medical homes.

    3. Member:

      A policyholder or eligible spouse or dependent who is properly enrolled in a health plan.

  7. O

    1. Open Enrollment Period (OE): 

      The period from November 1st through January 15th which the member has the opportunity to enroll for coverage without requiring a Qualifying Event.

    2. Out-of-pocket maximum:

      The total amount of copayments, coinsurance and deductible that a member must pay in a calendar year before the plan begins to pay 100 percent for covered services within that calendar year.

  8. P

    1. Participating provider:

      A healthcare provider or facility with an agreement to participate with Providence Health Plan. When you use participating providers, you receive in-network benefits.

    2. Policyholder:

      The policyholder must be at least 18 years old, is financially responsible for the policy and is the person authorized to make changes to the plan.

    3. Premium:

      The monthly fee you pay for health plan coverage. Premium rates are subject to change at the beginning of each plan year.

    4. Primary care provider (PCP):

      A participating provider who has agreed to provide or coordinate medical care and is listed in the primary care provider section of the provider directory.

    5. Provider network:

      A provider network is a collection of providers, hospitals and facilities that have agreed to set reimbursement rates for healthcare services delivered to members of a health insurance plan. Providence Health Plan has three networks that are matched to our various plans.

  9. Q

    1. Qualifying Event (QE):

      When an individual experiences a Qualifying Event, they can apply for new coverage or make changes to their current policy outside the Open Enrollment Period. Examples include losing employer coverage, marriage and the birth of a child. See the full list of qualifying events.

  10. S

    1. Service area:

      The geographic area in Oregon or Washington where the policyholder, spouse, Oregon child-only member or Washington dependent-only member must physically reside in order to be eligible for coverage. Plan availability may vary by county.

      See our service areas

    2. Special Enrollment Period (SEP):

      An individual who experiences a qualifying event during the period from January 1st through December 31st is eligible for a Special Enrollment Period. Providence Health Plan must receive a new applicant's completed application or an existing policyholder's completed change form within 60 days of the qualifying event.

    3. Subscriber:

      The primary enrollee on the Individual and Family insurance policy. On an Oregon child-only or a Washington dependent-only policy, this person is not considered a subscriber since they are not enrolled for coverage; but they are still a policyholder.

For more healthcare terms and definitions, visit HealthCare.Gov/Glossary.

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