Health coverage is not the easiest thing to understand, and we get it! Here at the Oregon Health Insurance Marketplace, our goal is to help make coverage more digestible. Even though the jargon can feel like a foreign language, once you get the hang of it, it's easy to understand.
Here are some of the most used jargon and what they mean:
Premium
The monthly out-of-pocket cost to have coverage. The premium will stay the same month to month, but may change from one year to the next.
Co-payment
A set amount you pay upfront, such as $20 for a doctor visit.
Co-insurance
A percentage of the service costs that you pay.
Deductible
The amount you pay for services before your plan begins to pay at a higher rate. Every plan covers preventive services before you meet your deductible.
Maximum out of pocket
The most you will pay out of pocket in a plan year before your plan pays for 100 percent of covered services. If you reach your maximum out of pocket, you still need to pay your premium to have active coverage.
Network (in network)
A group of providers or facilities that your plan works with. You may pay more to visit a provider who is out of network.
Essential health benefits
All plans sold through the Marketplace must cover this list of 10 categories of services. In Oregon, these essential health benefits include:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Pediatric services, including oral and vision care
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
Preventive services
Under both Oregon and federal laws, all Marketplace plans must provide preventive care services. These services are available at no cost to members, as long as the members get the service from an in-network provider. This means your doctor cannot charge your co-pays, deductibles, or co-insurance when providing preventive care. You should work with your doctor to figure out which services you should take advantage of.
Preventive care includes the following and more:
- Flu and pneumonia shots
- Well-woman visits
- Contraception
- Regular well-baby and well-child visits from birth to age 21
- Breastfeeding support, supplies, and counseling, including the cost of renting breastfeeding equipment
- Counseling, screening, and vaccines to ensure healthy pregnancies
- Blood pressure, diabetes, and cholesterol tests
- Many cancer screenings, including mammograms and colonoscopies
- Counseling and treatment to stop smoking
- Counseling for weight loss and healthy eating
- Depression screening
- Counseling to reduce alcohol use or treat problem drinking
- Routine vaccinations for children and adults against diseases such as measles, polio, and meningitis
You can learn more about preventive care on the
U.S. Preventive Services Task Force website.
Open enrollment
This is the time when most people can shop and enroll in health coverage for the new year. In Oregon, open enrollment begins Nov. 1 and ends Dec. 15 for coverage beginning Jan. 1 of the following year.
Qualifying life event
An event that may allow you to shop, enroll, or change plans mid-year. These events may trigger a special enrollment period. Qualifying life events include:
- A change in income that changes your eligibility for financial assistance
- Birth, adoption, or placement of a child in your home
- Divorce or death in the family
- Gaining citizenship or qualifying immigration status
- Getting married
- Getting released from incarceration
- Losing coverage involuntarily, including Oregon Health Plan, job-based coverage, or a student plan
- Moving
- Turning 26 and losing coverage through a parent/guardian's plan
Special enrollment period
If you have a qualifying life event, you may be able to enroll or change plans mid-year under a special enrollment period. You have 60 days to report your life change and to enroll or make changes. If you qualify for a special enrollment period, you will likely need to submit proof of your life event.
Premium tax credit
One type of financial assistance available through the Marketplace. You can use these tax credits to lower your premium each month. You can use some, all, or none of the tax credits you qualify for to lower your monthly premium. Any tax credits that you use must be reconciled at the end of the year on your taxes. It is important to report any changes you experience throughout the year, such as household or income changes to get the right amount of tax credits.
Cost-sharing reductions
These discounts lower out-of-pocket costs such as deductibles, co-payments, co-insurance, and out-of-pocket maximum. Typically, you can get these extra savings only on Silver level plans through the Marketplace. If you're an enrolled tribal member or Alaska Native Claims Settlement Act (ANCSA) shareholder, you may be able to enroll in any plan through the Marketplace and get these savings.