Glossary of health insurance terms

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

Calendar year
The period from Jan. 1 through Dec. 31 each year

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.

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.

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.

Dependent
The policyholder's spouse or eligible family member

Effective date of coverage
The date upon which coverage begins

Exclusion
A service or supply not covered by the health plan

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

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

Member
A policyholder or eligible spouse or dependent who is properly enrolled in the plan.

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.

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

Premium
The monthly rate you pay for health plan coverage.

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.

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.

Service area
The geographic area in Oregon 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.