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Helpful Definitions
- Calendar year
- Marks the time beginning January 1 and ending December 31.
- Coinsurance
- The percentage of cost that you must pay for a covered service.
- Copayment
- A dollar amount you must pay to a health care provider at the time you receive service.
- Deductible
- The amount you pay for certain covered services before the plan begins to pay for these services. A new deductible must be met each calendar year.
- Dependent
- A person who is supported by the policyholder or policyholder's spouse.
- Domestic Partner
- A domestic partner, as defined by Providence Health Plan, is at least 18 years of age; has entered into a domestic partnership with a member of the same sex; and has 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 when coverage starts for a newly enrolled health plan member.
- Lifetime maximum benefit
- The total dollar amount of benefits payable under the Plan Contract during the lifetime of a member.
- Member
- A policyholder, eligible spouse or dependent who is enrolled in the plan.
- Non-participating provider
- A provider or facility with no agreement to participate with Providence Health Plan. When using nonparticipating providers you receive "Out-of-Plan" benefits.
- Participating provider
- A provider or facility with an agreement to participate with Providence Health Plan. When you use participating providers you receive "In-Plan" benefits and have less costs.
- Plan Contract
- The legal agreement between the policyholder and Providence Health Plan, detailing plan benefits, enrollment requirements and information about your coverage.
- Policyholder
- The person to whom the Plan Contract has been issued. A policyholder must be age 18 or older. If enrolling for dependent-only coverage, the parent/guardian applying will be the policyholder.
- Premium
- The monthly rate you pay for health plan coverage.
- Pre-existing condition
- Any medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to effective date of coverage.
- Service area
- The geographic area in Oregon, where the policyholder, spouse of policyholder or child-only member must physically reside to qualify for coverage.
- Summary of Benefits
- A description of your plan benefits, copayments/coinsurance, deductibles and out-of-pocket maximums and is part of your Plan Contract.
- Usual, Customary And Reasonable (UCR) Charges
- Charges for services provided by nonparticipating providers, UCR means charges billed by providers with similar training and experience.
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