Health plan glossary

A C D E L M O P S

  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:

      The period from January 1st through December 31st each year.

    2. Coinsurance:

      A percentage of the amount you are responsible to pay a health care provider for a covered service. For example, if a health care 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:

      A fixed dollar amount that you are responsible for paying to a health care provider at the time you receive the service. 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 amount you must pay for services that are covered by the health plan before your plan will begin to pay for these services. A new deductible must be met each calendar year.

    2. Dependent:

      The policyholder’s spouse or eligible family member.

  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.

      • Oregon residents: If you qualify for for a tax credit or subsidy to help pay for your coverage, you must buy your health plan through the Federal Health Insurance Marketplace, located at HealthCare.gov
      • Washington residents: You may purchase Providence plans through the Washington Health Benefit Exchange, located at WaHealthPlanFinder.org
    2. Medical Home:

      A cooperative, patient-centered clinic made up of providers and staff who work with you to address your physical & mental 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. Out-of-pocket maximum:

      The total amount you will pay in deductible, copays and coinsurance for covered services in a calendar year. After you meet your plan’s out-of-pocket maximum, the plan will pay for 100 percent of covered services for the remainder of the 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. Premium:

      The monthly fee you pay for health plan coverage.

    3. Primary care provider:

      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.

    4. Provider network:

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

  9. S

    1. Service area:

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

      See our service areas

For more healthcare terms and definitions, visit healthcare.gov/glossary

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