Affordable Care Act (ACA) — The comprehensive federal health care reform law that established health insurance marketplaces and financial subsidies to expand access to affordable coverage.
Advance Premium Tax Credit (APTC) — The advance payment of the Premium Tax Credit (PTC) sent to a carrier to reduce monthly premiums for eligible QHP enrollees. The APTC amount is based on household size, projected income (MAGI), and the second-lowest cost silver plan (SLCSP) premium in the enrollee's service area.
American Indian/Alaska Native (AI/AN) — A member of a federally recognized Tribe or Alaska Native entity acknowledged by the U.S. Department of the Interior, including ANCSA regional village corporations. AI/AN status affects CSR eligibility and cost-sharing rules.
Applicant — A person who applies for health coverage through Explore Health.
Applicant Portal (Explore Health Consumer Portal) — The state‑run online system allowing applicants to apply for, shop for, and enroll in coverage through Explore Health. (Public URL to be finalized and published prior to OE.)
Authorized Representative — An individual chosen by the applicant to act on their behalf to create and/or update the application or enrollment; may have legal authority.
Binder Payment (Initial Payment) — The first month's premium payment due to the carrier to effectuate coverage under the selected QHP. If not paid by the carrier's deadline (including required grace periods), coverage does not take effect. Binder payment and effectuation do not apply to re‑enrollment in the same plan from one year to the next.
Catastrophic Health Plan — A QHP type meeting 45 CFR §156.155 requirements. Available without additional documentation to applicants under age 30; applicants 30 or older must have an approved hardship exemption to purchase a catastrophic plan. APTC cannot be used on catastrophic plan premiums. Note: Oregon carriers currently do not offer catastrophic plans; while hardship exemptions can be obtained, they yield no practical benefit in Oregon at this time.
Centers for Medicare & Medicaid Services (CMS) — The federal agency that regulates Medicare, Medicaid, and Marketplace programs.
Certified Application Assister (CAA) — An individual affiliated with a community partner/organization and certified by Explore Health to help applicants understand and apply for coverage. CAAs must provide fair, accurate, and impartial information but cannot recommend specific plans.
Certified Grantee Assister (CGA) — A CAA affiliated with a Grantee Organization (employee or volunteer) who provides outreach, education and Marketplace and OHP enrollment support to communities in Oregon.
Contact Center (Explore Health Contact Center) — Provides customer support to applicants, assisters, carriers, and certified agents via phone and a ticketing system. (Phone numbers and mailing address to be finalized and published on the website and in notices.)
Cost-Sharing Reduction (CSR) Plans — QHP variants with reduced cost-sharing (e.g., lower deductibles and copays) available to applicants with household MAGI ≤250% FPL and to AI/AN applicants at any income (learn about cost-sharing reductions for American Indians and Alaska Natives).
Data Matching Issue (DMI) — A discrepancy between information reported in the application and data returned from electronic sources (e.g., IRS, DHS, ONE). DMIs trigger a Reasonable Opportunity Period (ROP) for applicants to provide documentation.
Dependents — Individuals who may be claimed as tax dependents on the federal tax return (e.g., child).
Effectuated Coverage — Coverage is effectuated when the applicant's binder payment is received and the carrier has an active account for the person. (Re‑enrollment in the same plan is already effectuated; no binder needed.)
Eligibility Determination Notice (EDN) — The official Explore Health notice communicating the outcome of an eligibility determination or redetermination (term used within appeals timelines).
Enrollment Partners — Explore Health-certified private sector entities and individuals (e.g., community partners, CAAs, and agents,) who help consumers shop for and enroll in coverage and financial assistance.
Essential Health Benefits (EHB) — Services QHPs must cover under the ACA (ambulatory, emergency, hospitalization, maternity/newborn, mental health/SUD, Rx, rehab/habilitative, lab, preventive/chronic disease management, pediatric including dental/vision, contraception, breastfeeding). In Oregon, QHPs are not required to include pediatric dental if a Stand Alone Dental Plan (SADP) is available; SADPs must provide pediatric dental.
Federal Poverty Level (FPL) — Income measure issued annually by HHS used for eligibility determinations. (Used across APTC/CSR calculations and eligibility.)
Grantee Organization - A community-based organization that receives funding from Explore Health through a formal grant agreement to conduct outreach, education, and in person application assistance for individuals seeking health coverage. These organizations employ or host Certified Grantee Assisters, who are trained and certified by Explore Health to provide fair, accurate, and impartial support to applicants.
Hardship Exemption — Exemption allowing applicants age 30+ to enroll in catastrophic coverage if affordable coverage is unavailable per IRS affordability thresholds, or if not eligible for CSR/PTC. Note: Oregon carriers currently do not offer catastrophic plans; this exemption can be obtained but does not provide any benefit.
Household (for Tax/Eligibility Purposes) — Primary applicant (tax filer), spouse (if filing jointly), and any tax dependents expected to be claimed for the benefit year. (Terminology standardized.)
Individual Coverage Health Reimbursement Arrangement (ICHRA) — An employer-funded HRA alternative to group coverage; eligibility for ICHRA may trigger SEP rights and affects APTC eligibility, per federal rules.
Insurance Agent — A DCBS-licensed agent certified by Explore Health to assist applicants with Marketplace coverage. Agents may recommend specific plans and are appointed and compensated by carriers via commission.
Minimum Essential Coverage (MEC) — Coverage meeting ACA requirements (e.g., employer coverage, QHPs, OHP programs including Healthier Oregon and OHP Bridge, Medicare A/Medicare Advantage, certain VA/TRICARE programs, Peace Corps, Non‑appropriated Fund Health Benefit Program, Refugee Medical Assistance, expatriate plans, approved student plans/state high‑risk pools for pre‑2015 plan years, and other coverage recognized by HHS).
Mixed CSR Status Household — A household in which some members are eligible for CSR variants and others are not, or members qualify for different CSR levels (e.g., one enrolled Tribal member and one non‑member).
Oregon Eligibility (ONE) System — State system that determines eligibility for OHP programs and other benefits (e.g., SNAP, TANF).
Oregon Health Plan (OHP) — Oregon's Medicaid umbrella (OHP, OHP Bridge/Basic Health Program, Healthier Oregon—Medicaid look‑alike for non‑citizens). OHP eligibility is determined via ONE.
Open Enrollment (OE) — Annual period (generally Nov 1–Dec 31) when consumers can enroll in individual coverage for the next plan year. (Dates for PY 2027: Nov 1–Dec 31, 2026.)
Periodic Data Matching (PDM) — Twice-yearly checks against data sources (e.g., Medicare, ONE) to identify applicants enrolled in QHPs with subsidies while eligible for or enrolled in other programs; used to prevent duplication of benefits.
Plan Year (PY) — The 12‑month coverage period (Explore Health plan years run Jan 1–Dec 31).
Premium Tax Credit (PTC) — Federal tax credit that helps eligible individuals and families cover premiums for plans purchased through Explore Health; can be taken at tax filing or in advance (APTC). The amount is based on household size, projected income (MAGI), and SLCSP premium in the service area.
Qualified Health Plan (QHP) — A Marketplace-certified plan that provides EHBs, follows cost-sharing limits, and meets ACA requirements. (Certification conducted by Explore Health.)
Qualifying Life Event (QLE) — A significant life event/change in circumstances (e.g., marriage, birth, loss of coverage) that makes an applicant eligible for an SEP to enroll outside OE.
Reasonable Opportunity Period (ROP) — Time allowed for applicants to provide proof and clear DMIs (generally 90 days for application-derived DMIs; 30 days for program integrity DMIs such as those from PDM).
Reasonably Compatible — A determination that information from data sources and applicant attestation do not materially affect eligibility, APTC amount, or CSR category; discrepancies that do not impact outcomes are considered reasonably compatible.
Small Business Health Options Program (SHOP) — Marketplace for small employers (§42 U.S.C. 18031). Explore Health certifies small group plans as QHPs/SADPs; employers enroll via carriers or agents. Eligible small employers may qualify for the Small Business Health Care Tax Credit if they offer SHOP coverage.
Special Enrollment Period (SEP) — Time outside OE when an applicant can enroll due to a QLE. (See Section 8.)
Special Enrollment Period Verification Issue (SVI) — Verification to confirm a QLE for SEP enrollment outside OE.
Stand Alone Dental Plan (SADP) — Dental-only plan (includes mandatory pediatric dental). Applicants typically select SADPs when dental benefits are not embedded in their QHP; SADPs are not available without a QHP. Remaining APTC after QHP may be applied to the pediatric EHB portion of SADP premiums.
Primary Contact — The primary tax filer is the default primary contact for the QHP application and is assigned as the subscriber unless not seeking coverage; if not seeking coverage, the oldest adult applicant becomes subscriber; for child-only applications, the youngest child is set as subscriber.
Tax Filer — An individual or married couple expecting to file a return for the benefit year (jointly if married), not claimed by another taxpayer, and expecting to claim personal exemptions for one or more applicants.
Tobacco User — An applicant who attests to using tobacco products four or more times per week within the last six months as of the application date. (Reporting rules in Section 5.4.)