Glossary of Terms

Open Enrollment Period

The period of time each year when eligible individuals can enroll in a Qualified Health Plan through Washington Healthplanfinder. Individuals may also qualify for special enrollment periods outside of open enrollment if they experience certain events. (See Special Enrollment Period and Qualifying Life Event.) You can apply for Washington…

Out-of-Network Co-Insurance

The percent of the doctor, clinic or other provider’s bill for covered services that you must pay when the provider is not in your plan’s network, for example 40% of the bill amount. Out-of-network co-insurance usually costs more than in-network co-insurance.

Out-of-Network Co-Payment

A fixed amount (for example, $30) you pay at the time you receive covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually cost more than in-network co-payments.

Out-of-Network Provider

A doctor that is not on the selected health plan’s approved list of health care providers. The health plan may not cover services provided by this doctor, and you may be required to pay for services out of pocket, at a higher charge than in-network services.

Out-of-Pocket Costs

Your expenses for medical care that are not reimbursed or covered by insurance. Out-of-pocket costs include deductibles, co-insurance, and co-payments for covered services, plus all costs for services that are not covered by your plan.  …

Out-of-Pocket Estimate

An estimate of the amount that you may have to pay on your own for health care or prescription drug costs. The estimate is made before your health plan has processed a claim for that service.

Out-of-Pocket Maximum/Limit

The maximum amount you will pay in 1 calendar year for health services, not including premium payments or out-of-network costs. This limit must include deductibles, co-insurance, co-payments, or similar charges. It must include any other expenditure required of an individual that is a qualified medical expense for the essential health…