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

Domestic Partner

A Domestic Partner must be a member of the Policyholder’s same sex, 18 years of age or older, and must have legally registered a Declaration of Domestic Partnership and obtained a Certificate of Registered Domestic Partnership in accordance with Oregon state law.

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.

Medical Home

A medical home is a cooperative, patient-centered clinic made up of providers and staff who work with you to address your physical & mental health needs and goals. The medical home you choose coordinates all elements of your care across hospitals, specialists, pharmacies, home health services, and community resources to ensure greater accessibility, shorter wait times, and an integrative approach to your health.

Member

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

Open Enrollment Period

The period from November 1 – December 15 during which the applicant has the opportunity to enroll for coverage without requiring a Qualifying Event.

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.

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.

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.

Qualifying Event (QE)

Examples of a Qualifying Event include losing employer coverage, marriage and the birth of a child. See the full list of Qualifying Events at ProvidenceHealthPlan.com/qe.

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.

Special Enrollment Period (SEP)

An individual who experiences a Qualifying Event during the period from January 1 – December 31 is eligible for a Special Enrollment Period. The enrollee must submit a complete application within 60 days of the Qualifying Event and pay the initial month’s premium prior to enrollment.

Subscriber

A subscriber is the primary enrollee on the Individual and Family Insurance policy. They are also considered the financially responsible person for the policy. On a child-only policy, this person is not considered a Subscriber since they are not enrolled for coverage; but they are still a Policyholder.

Wet signature

A signature is consider valid only if it is handwritten (“wet”). All policy change requests submitted by the policyholder must include a wet signature.