Types of Coverage
This type of Health Plan is provided by non-governmental commercial entities rather than public programs. They are generally obtained through employers, unions or via direct purchase through a marketplace.
Private Health Plan
The is the "Hospital Insurance" component of original Medicare. It primarily covers hospital stays, SNF care, Hospice and Home Health Services.
The free state funded Medicaid program providing health coverage to eligible low-income Oregon residents including adults, families, children and seniors.
Oregon Health Plan (OHP)
The amount of money an individual or business pays to an insurance company in exchange for coverage. This is not typically counted as part of a member's cost share.
Premium
A healthcare professional - typically a MD, DO, NP or PA - who serves as the main, first-contact point for a patient's long term comprehensive health care needs. They provide preventative care, treat common illnesses, manage chronic conditions and coordinate referrals to other providers with more expertise in specific areas of medicine. They typically work in the fields of Family Medicine, Internal Medicine or Pediatrics.
Primary Care Provider (PCP)
This type of health plan is provided by a government-funded or subsidized program that provides health coverage to individuals with special needs such as the elderly, those with disabilities, US Veterans and those with low income.
Public Healthcare Plan
This is the "Medical Insurance" component of Medicare. It is a voluntary federal medical insurance program for people 65+ or with specific disabilities that covers outpatient care, doctor visits, preventative services and DME.
Medicare Part B
Samaritan Health Plan's Medicaid plan has different branding from its other health plans. What is the name of Samaritan Health Plan's Medicaid plan?
Intercommunity Health Network CCO (IHN-CCO)
The specific amount of money you must pay out-of-pocket for covered expenses before your insurance begins to pay for claims.
Deductible
A Physician, NP or PA who has completed advanced education and clinical training in a specific area of medicine such as cardiology, oncology or dermatology. They focus on diagnosing, managing and treating particular diseases, symptoms, and patient populations.
Specialist
This type of managed care health insurance plan provides coverage through a specific network of doctors and hospitals. It requires prior authorizations through the health plan to see any out of network providers or have any out of network services performed.
Health Maintenance Organization (HMO)
This is the "Medicare Advantage" component of Medicare. It is an alternative to Parts A and B where the member pays an extra on top of their Medicare premiums to a private commercial insurance provider for "All-in-One" coverage including extra benefits like dental, vision, and hearing.
Medicare Part C
This type of health plan is a local, community-based network of healthcare providers that partner with Oregon Health Authority and OHP to manage Oregon Medicaid plans on a local level.
Coordinated Care Organization (CCO)
A fixed out-of-pocket amount you pay for a covered health service - such as a doctor's visit or prescription - due at the time of service. It is a predetermined fee that varies by service type.
Copay
An entity - such as a Hospital, SNF, Lab or DME - licensed to furnish medical services, equipment or supplies to patients. Unlike individual practitioners, these institutions are structured organizations that provide care and are under contract with insurances and bill as an entity rather than individuals within a group.
Facility
This type of health plan provides a network of doctors, hospitals and specialists that allows members to seek care inside the network for lower costs than outside the network, where they have higher fees. They can see a provider anywhere as long as they are credentialed with the plan.
Preferred Provider Organization (PPO)
This is the "Pharmacy Insurance" component of Medicare. It is an optional, federally approved insurance program that is managed solely by private commercial insurance companies where members pay a premium on top of their Medicare Part A and B premiums to get coverage and lower costs on brand name and generic medications, as well as certain vaccines. This benefit is often included as part of Medicare Advantage Plans.
Medicare Part D.
This type of Oregon Health Plan coverage occurs when a member is not assigned to CCO due to a special circumstance decided upon by Oregon Health Authority allowing the member to see any provider who accepts OHP, regardless of service area. OHP is also billed directly for any services.
Open Card (or Fee-for-Service) Plan
A cost-share where you pay a percentage of a covered services costs after the service is billed while the insurance company pays the rest. This cost share typically goes into effect only after you have met your deductible.
Co-Insurance
This is the business process where healthcare providers negotiate and sign agreements with health insurance companies to join their network, defining reimbursement rates for services.
Contracting
This type of health plan follows a traditional employer-sponsored insurance model where the employer, the member themselves (Medicare) or the Government (Medicaid), pay fixed monthly premiums to an insurance carrier. The carrier assumes all financial risk, manages claims and handles administration, thereby providing budget predictability for the Employer/Member/Government program.
Fully Funded
This type of Medicare Advantage Plan is designed specifically for individuals who qualify for both Medicare and Medicaid. Medicare Advantage assumes the role of the primary insurance, while Medicaid functions as the secondary insurance. At Samarian Health Plans, this type of plan is branded as the "Dual Advantage Plan."
Dual Eligible Special Needs Plan (D-SNP)
A prepaid managed care organization that contracts with OHA to provide dental care for Medicaid recipients. CCOs are able to assign members to these organizations, but each organization handles the member's dental benefits themselves.
Dental Care Organization (DCO)
The absolute most you will pay for covered health insurance services in a plan year. Once this limit is reached through deductibles, copays and coinsurance, the insurer pays 100% of covered medical and prescription costs.
Out-Of-Pocket Maximum (OOP Max)
The formal mandatory process of verifying a healthcare provider's qualifications, including education, ongoing training, licenses, and work history to ensure they meet professional standards. Providers must complete this process with each insurance in a given area every time they begin a new job or move locations.
Credentialing