Health insurance glossary

Terms and definitions

Here are definitions of a few key terms to help you better understand how we talk about healthcare.

Accident benefit

Coverage for care when members have an accident. Standard cost-sharing applies after reaching the dollar maximum or after 90 days, whichever comes first.

Advanced premium tax credit (APTC)

A federal tax credit that can help members pay for their medical plans when they apply through You may qualify for this type of financial assistance based on household size and income.

Affordable Care Act (ACA)

The Affordable Care Act (ACA) — sometimes referred to as Obamacare — is a federal law that offers certain protections, such as no pre-existing condition restrictions. It also requires people to have health insurance (with some exceptions). To learn more, visit

Annual maximum plan payment limit

The maximum dollar amount a dental plan will pay toward the cost of dental care for members ages 19 and older within a calendar year.

Balance billing

Charges for out-of-network care beyond what your health plan allows. Out-of-network providers may bill members the difference between the maximum plan allowance (or reimbursement amount) and their billed charges when permitted by law. In-network providers don’t do this for covered services.


The percentage members pay for a covered healthcare service or supply after they meet their deductible. For example, they may pay 20% of an allowed $200 charge, or $40.

Copay (copayment)

The fixed amount members pay for a specific covered healthcare service or supply, usually at the time of receiving it. For example, they might pay $25 for a doctor visit.

Cost-sharing reductions

A type of federal financial assistance that lowers out-of-pocket costs, like deductibles, copays and coinsurance. This reduction may be available to people who apply through and who qualify based on household income. Members of a federally recognized tribe might be eligible for other cost-sharing benefits.


The amount members pay in a calendar year for care that requires a member contribution before the health plan starts paying. Fixed-dollar copays and prescription medications may not apply toward the deductible. Disallowed charges do not apply toward the deductible.

Exclusive Provider Organization (EPO)

A type of provider network. An EPO network includes providers contracted with Moda Health to offer in-network coverage at agreed-upon rates. There are no out-of-network benefits with an EPO plan except for medical emergency services and retail pharmacy services, and some out-of-area children, unless you are in an in-network facility and you do not have a choice of providers.

If you have children you want to cover as dependents who live in the US outside of Oregon, they may be eligible for out-of-area benefits if they are full-time students age 18 to 26 or if you have a qualified medical child support order (QMCSO). In Oregon, all of your family members must use providers in your network to be covered.

Evidence-based practices

Healthcare options or decisions that research shows work best, are most cost-effective and consider the patient’s needs and experience.

In-network provider

A person or place contracted with a provider network to provide care.

Inpatient care

Care people receive while they are checked in to a hospital or facility. Usually, people are admitted to a hospital only if they are seriously hurt or sick.

Metal category

Medical plan levels defined by the Affordable Care Act (ACA). Categories include Gold, Silver and Bronze. Plan benefits range in coverage and cost based on the metal level. Generally, Gold plans offer more coverage but have higher premiums. Silver plans fall in the middle, while Bronze plans offer less coverage with lower premiums.

Non-preferred tier medications

Medications, including specialty medications, that have been reviewed by the Moda Health Pharmacy & Therapeutic Committee and found to have no significant therapeutic advantage over their preferred tier alternatives. These products generally have safe and effective options available under value, select and/or preferred medication tiers.

Off-exchange plan

A health insurance plan that is purchased directly from an insurance company, agent or broker outside of the official Federally Facilitated Marketplace (FMM).

On-exchange plan

A health insurance plan that is only available on the Federally Facilitated Marketplace (FMM). If you qualify for a subsidy, your best option is to use it for an on-exchange health plan.

Out-of-pocket costs

What members pay in a calendar year for care after their health plan pays its portion. These expenses may include deductibles, copays and coinsurance for covered services.

Out-of-pocket maximum

The most members pay in a calendar year for covered care and services before benefits are paid in full up to the allowable amount or up to any visit or dollar limit. Once members meet their out-of-pocket maximum, the plan covers eligible expenses at 100%. The out-of-pocket maximum includes deductibles, coinsurance and copays. It does not include disallowed charges or balance billing from out-of-network providers. For dental plans, an out-of-pocket maximum only applies to in-network care for members under age 19.

Outpatient care

Care received from a doctor's office or other provider, without being checked into a hospital or facility.

Pediatric dental care

Dental care for members under age 19, which may be included in a medical or dental plan.

Pediatric vision benefit

A medical plan benefit that covers vision care for members under age 19.

Pre-existing condition

Under the Affordable Care Act, if you were sick or had a health problem before applying for health coverage, you won’t be denied based on that reason.

Preferred tier medications

Preferred medications, including specialty preferred medications, have been reviewed by the Moda Health Pharmacy & Therapeutic Committee and found to be safe and clinically effective at a favorable cost when compared with other medications in the same therapeutic category. Generic medications may be included in this tier when they have not been shown to be safer or more effective than other more cost-effective generic medications. If a member requests, or the treating physician prescribes, a brand medication when a generic equivalent is available, the member will be responsible for the brand cost sharing plus the difference in cost between the generic and the brand medication.

Preferred provider organization (PPO)

A type of provider network. For our plans, a PPO network includes providers contracted with us to offer in-network coverage at agreed-upon rates, with no balance billing.


The monthly amount members pay to be covered by a health or dental plan.

Preventive care

Routine, in-network medical care that helps keep members healthy. Services include periodic health exams, well-baby care, women’s annual exams, preventive health screenings and immunizations.

Primary care provider (PCP)

The healthcare provider who treats members or coordinates their care to keep them healthy. Examples of a PCP include an M.D. (Doctor of Medicine), D.O. (Doctor of Osteopathic Medicine), nurse practitioner or physician assistant. These providers may practice primary care in the specialties of internal medicine, family medicine, general practice, geriatric medicine, pediatrics and women’s health, among others.


Any group or professional that provides members with care. Examples are hospitals, doctors and rehabilitation centers.

Select tier medications

Generic medications that represent the most cost effective option within their therapeutic category. Certain brand medications that have been identified as both clinically favorable and cost effective are also included.

Special Enrollment

The period outside of open enrollment that allows those who qualify to enroll in a new or different health plan and/or to add members. Certain life events like getting married, having a baby or moving to a new state could make members or covered dependents eligible for Special Enrollment.


A medical provider specializing in a specific type of health condition or care. Specialists might include cardiologists, dermatologists, oncologists, urologists and many others.

Specialty medications

Medications that are often used to treat complex chronic health conditions and may require special handling, careful administration and a unique ordering process.

Urgent care

Short-term medical care provided by an urgent care facility for minor but urgent medical conditions that aren’t severe enough to require emergency room care.

Value tier medications

Commonly prescribed medications used to treat chronic medical conditions and preserve health.

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