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 plan 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
      A Domestic Partner must be 18 years of age or older; at least one partner must be a resident of Oregon; and neither partner can presently be in a marriage or a legally recognized registered domestic partnership.

      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, spouse, domestic partner, or eligible family dependent who is properly enrolled in a health plan.

7. O

   1. Open Enrollment Period (OEP): 

      The period from November 1st through January 15th when individuals can apply for new coverage or make changes to their current policy 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 plan year before the plan begins to pay 100 percent for covered services within that plan 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. Plan Year:

      The 12-month period when the approved plan benefits and premium rates for your plan contract are in effect. For Individual & Family plans, the plan year begins on January 1; for Group plans, it is at the employer's discretion.

   3. 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.

   4. Premium:

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

   5. Primary care provider (PCP):

      A Primary Care Provider is a healthcare professional who specializes in family practice, general practice, internal medicine, or pediatrics. They can also be a nurse practitioner or a physician associate working with a primary care physician. Members can pick a doctor specializing in women's health, obstetrics or gynecology, a nurse midwife, or a physician associate as their Primary Care Provider. Children can choose a pediatrician as their Primary Care Provider.

   6. 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 of 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 & 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.