Glossary of health insurance terms

Acute care
is care received in an inpatient hospital setting.

Benefit summary
is a description of your benefits and copayments. If you are a commercial Providence Health Plan member, you can view your benefit summary online once you have registered for a myProvidence account.

Calendar year
is January 1 through December 31.

Certificate of Creditable Coverage
provides proof of prior medical coverage. You may need to furnish this certificate to another insurance carrier to obtain medical coverage in the future.

Certified nurse midwife
is a person who is licensed or certified to supervise the conduct of labor and childbirth; advise the parent as to the progress of the childbirth; and furnish prenatal, intrapartum and postpartum care.

Coinsurance
is the percentage of cost that you may need to pay for a covered service. The Plan pays the rest of the cost of the service. Coinsurance amounts are listed on your benefit summary.

Condition
is an impaired state of health, due to a specific illness or injury that requires skilled professional treatment or services.

Copayment / copay 
is the fixed dollar amount you pay for a covered service at the time the care is provided. Copays are listed on your benefit summary.

Cosmetic treatment
is defined as medical or surgical treatment primarily for the purpose of improving appearance or self-esteem.

Custodial care services
are services or supplies that do not require the technical skills of a licensed nurse at all times, assist solely in activities of daily living activities or personal grooming and are not likely to improve your condition.

Deductible
is the amount of money that an individual must pay out-of-pocket for medical services before the health plan pay its portion. Deductibles are usually per person, or per family, per calendar year. For example, an individual may have a $200 deductible whereas a family may have a $400 deductible.

Dependent
means a person for whom you or your legal spouse provided, during the most recent calendar year, more than 50 percent of the person's support. In the case of a student, amounts received as scholarships for study will not be considered in determining source of support. If no one provided more than 50 percent of the person's support, the person will be treated as the dependent of whoever provided the most support. A child will also be considered a dependent if you or your spouse are required to provide medical care to a child under a qualified medical child support order, as defined by federal law.

Durable medical equipment (DME)
is equipment which is primarily and customarily used to serve a medical purpose, and generally is not useful to a person in the absence of illness or injury. It can withstand repeated use and is generally considered to be safe and effective for the purpose intended. DME may include items such as oxygen, wheelchairs, and other medically necessary equipment required for the treatment of an illness or injury.

An emergency medical condition
is a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate attention would place the health of a person (or a fetus, in the case of a pregnant woman) in serious jeopardy.

An employer group
refers to the organization whose employees are covered by the Plan.

Experimental, investigational or for research purposes
means services determined by Providence Health Plan or our authorizing agent to not be medically necessary or accepted medical practice in the service area. In determining whether services are experimental, investigational, or for research purposes, the Plan will consider whether services are, in general: used in the medical community in the state of Oregon; under continued scientific testing and research; show a demonstrable benefit for a particular illness; proven to be safe and efficacious and; approved for use by appropriate government agencies. The Plan includes a determination on a case by case basis of whether the requested service will result in greater benefits than other generally available services, and will not approve such a request if the service poses a significant risk to the health or safety of the patient. The Plan retains documentation of the criteria used to define a service deemed to be experimental, investigational or for research purposes and will make this available for review upon request.

A family practice physician
is a licensed personal physician/provider trained to diagnose and provide health care to patients of all ages. These providers are trained to provide routine gynecological care (including the annual gynecological exam) and some also provide obstetric care.

A general practice physician
is a licensed personal physician/provider trained to diagnose and provide health care services, including routine gynecological care and the annual gynecological exam, to patients of all ages.

A gynecologist
is a licensed physician specializing in the diagnosis and treatment of the diseases of women's reproductive systems. You may choose to have a Plan gynecologist provide your annual gynecological examination. Some gynecologists have been approved to act as personal physician/ providers and will be listed as such in the Provider Directory.

A member identification card
The card identifies you as a Plan member and includes important information about your coverage. Always present your card when you seek medical care or benefits.

Infertility
is defined as the inability to become pregnant after a year of unprotected intercourse or the inability to carry pregnancy to term as evidenced by three consecutive spontaneous abortions (miscarriages).

Integrated HSA, HRA and FSA 
Integrated HSA, HRA and FSA typically involves the combination of high-deductible health plan with a health care bank account, for example a health savings account (HSA) or health reimbursement arrangement (HRA). Individuals with CDHPs pay lower premiums for their health insurance because the deductibles are higher. The higher deductible can be offset by using funds set aside in an HSA or HRA.

An internist
is a licensed primary care provider who is trained to diagnose and provide health care services to adults and teens, including routine gynecological care and the annual gynecological exam for women.

Medically necessary
refers to treatment which, as determined by the Plan, is required to treat or care for symptoms of an illness or injury or to diagnose an illness or condition that is harmful to life or health. Medically necessary services or supplies must be: appropriate as to place or level of care in amount, duration, and frequency for the treatment of the condition; not be provided primarily for convenience; appropriate and in keeping with widely-accepted standards of practice in the community; and likely to stabilize or improve a member's medical condition. The fact that services are provided, prescribed or approved by a physician or provider does not in and of itself mean that the services are medically necessary.

Members
are the eligible individuals covered by Providence Health Plan.

A nurse practitioner
is a licensed nurse who has a master's degree in nursing and advanced training which allows him or her to provide primary care. Some nurse practitioners have been approved to act as personal physicians/providers and will be listed in the Provider Directory.

An obstetrician
is a provider specializing in the medical care related to pregnancy and the birth of children. Some obstetricians have been approved to act as personal physicians/providers and will be listed in the Provider Directory.

An out-of-area dependent
is an eligible family dependent of a subscriber, who does not reside in the Plan's service area and who is properly enrolled in the Plan as an out-of-area dependent. A dependent child who is an eligible family dependent and who resides out of the service area for the purpose of attending school is eligible to be enrolled as an out-of-area dependent. The subscriber's spouse is eligible to be enrolled as an out-of-area dependent.

Out-of-pocket maximum
is the limitation on the amount of money you will have to spend for specified covered health services in a calendar year. This maximum amount is shown on your benefit summary.

A pediatrician
is a personal physician/provider trained to diagnose and provide health care services to infants, children, and adolescents.

A physician assistant
provides medical services under the direction and supervision of a licensed physician. Some physician assistants have been approved to act as personal physicians/providers and will be listed in the Provider Directory.

Plan
means Providence Health Plan.

A participating provider or Plan provider
is any credentialed physician, provider, hospital, or facility which has an Agreement with Providence Health Plan to provide care to Plan members.

Preventive care services
Routine services such as screenings and immunizations for the purpose of health maintenance and/or the early detection of health care conditions. Providence Health Plan covers certain preventive care services in full when received from an in-network provider. For more information, read Coverage of Preventive Care Services or refer to your benefit summary and/or member handbook for details.

Prior authorized services
are services which require you and/or your provider to seek Plan confirmation before seeking or receiving care. Final determination will be based on the covered benefits and eligibility on the date of service.

A personal physician or provider
is a participating provider specializing in family practice, general practice, internal medicine or pediatrics; a nurse practitioner; a certified nurse midwife; or a physician assistant, when providing services under the supervision of a physician; who agrees to be responsible for the member's continuing medical care by serving as case manager. Adult female members may also select a provider specializing in obstetrics or gynecology; a nurse practitioner; a certified nurse midwife; or a physician assistant specializing in women's health care as their personal physician or provider. (Note: Not all these providers are personal physician/providers see the Provider Directory for a listing of designated personal physician/providers.)

A qualified practitioner
means a physician, women's health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides covered services within the scope of that license.

Riders (endorsements or supplemental benefits)
are any benefits purchased by your employer in addition to Providence Health Plan's basic health care coverage. Examples are: vision, alternative care, chiropractor prescription drug riders. Not all members have this coverage. Check your member materials to determine if your coverage includes rider benefits. You may view your materials online if you have a myProvidence account.

The Providence Health Plan service area
is a defined geographical area.

A skilled nursing facility (SNF)
is a convalescent or chronic disease facility which is accredited by the Joint Commission on Accreditation of Hospitals or certified as an "SNF" by the Secretary of Health & Human Services according to Title XVIII of the Social Security Act as amended, section (j).

A specialist
is a nurse, physician or other health care professional who has advanced education and training in one clinical area of practice.

A subscriber
is the employee of the Group whose employment or membership in the Group establishes eligibility for his or her dependents under the Providence Health Plan policy.

Usual, customary, and reasonable charges (UCR)
are charges that the Plan determines fall within a range of those most frequently charged for services and supplies. The amount determined is based on charges in the community where the services and supplies were furnished, by those who provide them.

A women's health care provider
is an obstetrician, gynecologist, physician assistant specializing in women's health, advanced registered nurse practitioner specializing in women's health or a certified nurse midwife practicing within the applicable lawful scope of practice.