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Oregon Health Plan terms

Use this list of terms to help you understand words and acronyms used in Oregon Health Plan letters and other materials.

Advocate - A person who gives you support or helps protect your rights.

Appeal - When you ask your plan to review a decision they made about covering a health care service. If you do not agree with a decision the plan made, you can appeal it and ask to have the decision reviewed.

Authorized representative - A person you say can make decisions and sign things for you. This person could be a family member or guardian. If you want an authorized representative, you must fill out a special form.

Benefits - The services that your health care plan pays for.

Community partner - A person or organization that helps people apply for health care. Community partners are local. Help is free.

Coordinated care organization (CCO) - A CCO is a local group of health care providers. They are doctors, counselors, nurses, dentists and others who work together in your community. CCOs help make sure OHP members stay healthy.

Copay or copayment - Your health plan pays for services but some plans charge the member a small fee. That fee is called a copay. OHP does not have copays.

Department of Human Services (DHS) – State agency that runs programs like Supplemental Nutrition Assistance Program (SNAP) and Medicare. DHS and OHA work together to make sure you have the care you need.

Durable medical equipment (DME) – Medical equipment like wheelchairs and hospital beds. They are durable because they last. They do not get used up like medical supplies.

Eligible - To meet conditions or requirements for a program.

Enroll - To join.

Emergency medical condition - An illness or injury that needs care right now. A physical health example is bleeding that won’t stop or a broken bone. A mental health example is feeling out of control or feeling like hurting yourself.

Emergency transportation - Using an ambulance to get to care. Emergency medical technicians (EMT) give you care during the ride or flight. This happens when you call 911.

ER and ED - Emergency Room and Emergency Department. This is the place in a hospital where you can get care right now.

Emergency services - Care you get during a medical crisis. These services help make you stable when you are in serious condition.

Excluded services - Things that a health plan doesn’t pay for. Services to improve your looks, like cosmetic surgery, and for things that get better on their own, like colds, are usually excluded.

Grievance - A complaint about a plan, provider, or clinic. The law says CCOs must respond to each complaint.

Habilitation services and devices – Services and devices that teach daily living skills. An example is speech therapy, for a child who has not started to speak.

Health insurance - A program that pays for some or all of its members’ health care costs. A company or government agency makes the rules for when and how much to pay.

Hearing - When you ask the Oregon Health Authority (OHA) to review a decision OHA or your plan made about covering a health care service. Hearings are held by an administrative law judge who is not part of your CCO or the Oregon Health Plan.

Home health care - Services you get at home to help you live better. For example, you may get help after surgery, an illness, or injury. Some of these services are help with medicine, meals, and bathing.

Hospice services – Services to comfort a person during end-of-life care.

Hospital inpatient and outpatient care – Inpatient care is when you get care and stay at a hospital for at least 3 nights. Outpatient care is when you get care at a hospital but do not need to stay overnight.

Household - Family that lives with you, like your spouse, your children, and other dependents who you would claim on your taxes. A household does not include roommates.

Medicaid - A national program that helps with health care costs for people with low incomes. In Oregon, it is part of the Oregon Health Plan.

Medically necessary - Services and supplies that your doctor says are needed. They are needed to prevent, diagnose, or treat a condition or its symptoms. It can mean services that a provider accepts as standard treatment.

Medicare - A health care program for people 65 or older. It also helps people with disabilities of any age.

Network - The group of providers that a CCO has a contract with. They are the doctors, dentists, therapists, and other providers that work together to keep you healthy.

Network provider - A provider the CCO chooses to have a contract with. If you see network providers, the CCO pays.

Non-network provider - A provider that does not have a contract with the CCO. They may not accept the CCO payment for their services. You might have to pay if you see a non-network provider.

Notice of Action - A letter that tells you when a decision is made about your health care.

Open card - If a member doesn’t have a CCO, they have open card. They can see any providers who accept Oregon Health Plan coverage.

Open enrollment - A period of time during the year when you can sign up for private health care. You can apply for OHP at any time during the year.

Oregon Health Authority (OHA) - The state agency that is in charge of OHP and other health services in Oregon.

Oregon Health Plan (OHP) – Oregon’s medical assistance program. It helps people with low incomes get access to care.

Patient-centered primary care home (PCPCH) - A health care clinic that focuses on the patient or member. It includes different providers all in one place.

Physician services - Services that you get from a doctor.

Plan - A company that arranges and pays for health care services. Most plans have physical, dental, and mental health care.

Preapproval (preauthorization) - Permission for a service. This is usually a document that says your plan will pay for a service. Some plans and services require this before you get the care.

Preferred Drug List (PDL) - A list of medications that are covered by OHP.

Premium - The cost of insurance.

Prescription drugs - Medications that your doctor tells you to take.

Prevention - What you do to help keep you healthy and stop you from getting sick. For example, checkups and flu shots.

Primary care provider (PCP) - The medical professional who takes care of your health. This is usually the first person you call when you have health issues or need care. Your PCP can be a doctor, nurse practitioner, physician’s assistant, osteopath, or sometimes a naturopath.

Primary care dentist - The main dentist who takes care of your teeth and gums.

Provider - A licensed person or group that offers a health care service. For example, a doctor, dentist, or therapist.

Renewal - OHP members must make sure they still qualify for health benefits. This is called renewing. It happens every year.

Rehabilitation services – Services to help you get back to full health. These help usually after surgery, injury, or substance abuse.

Skilled nursing care – Help from a nurse with wound care, therapy, or taking your medicine. You can get skilled nursing care in a hospital, nursing home, or in your own home.

Specialist – A provider trained to care for a certain part of the body or type of illness.

Urgent care – Care that you need the same day. It could be for serious pain, to keep you from feeling much worse, or to avoid losing function in part of your body.

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