Understanding Your Health Insurance
Having health insurance is an important step toward protecting your health and your wallet. But having insurance is only the first part. Knowing how to use it helps you get the care you need, without surprise bills or unnecessary stress.
Many people have questions about how insurance works. You’re not alone. Insurance can feel confusing, especially because not all insurance works the same way.
*If You Have the Oregon Health Plan (Medicaid)
Many costs you may hear about with private insurance (like copays, deductibles, and out-of-pocket maximums) usually do not apply to people on the Oregon Health Plan (OHP).
If you’re not sure what applies to you, our staff can help.
Insurance Terms Made Simple
Premium
A premium is the amount paid each month to keep an insurance plan active. This payment may be made by you, your employer, or Medicare.
Good to know: Most people on the Oregon Health Plan (Medicaid) do not pay a monthly premium.
Copay
A copay is a set amount that some people pay at the time of a visit or when picking up a prescription.
Important: Most Oregon Health Plan (Medicaid) members do not have copays for covered medical, dental, or behavioral health services. Copays are more common with private insurance or some Medicare plans.
Deductible
A deductible is the amount some people must pay each year before their insurance begins to cover costs.
Important: Oregon Health Plan (Medicaid) members do not have deductibles. Deductibles are common in private insurance plans.
Coinsurance
Coinsurance is a percentage of the cost that some people pay for services after meeting a deductible.
This usually applies to private insurance plans and does not apply to most Medicaid (OHP) members.
Out-of-Pocket Maximum
An out-of-pocket maximum is the most someone with private insurance may have to pay in a year for covered services.
This mostly applies to private insurance. Most Oregon Health Plan (Medicaid) members have little or no cost-sharing, so this usually does not apply.
Related: Understanding Medicaid Coverage & Oregon Health Plan
In-Network vs. Out-of-Network Care
Insurance plans work with certain doctors, hospitals, and clinics. These are called in-network providers. Providers without agreements with your insurance are out-of-network.
Seeing an in-network provider usually means:
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Lower costs
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Better coverage
Out-of-network care often costs more and may not be covered at all.
For Oregon Health Plan members: It’s especially important to see in-network providers, since out-of-network care may not be covered.
Always check your insurance card or call the number on the back to confirm coverage.
At NHC, we accept many insurance plans, including Medicaid (Oregon Health Plan), Medicare, and private insurance. Our staff can help you understand what your visit may cost.
What Your Insurance Covers
Most insurance plans cover preventive care like check-ups, screenings, and vaccines. This includes Medicaid, Medicare, and most private insurance plans.
Preventive care helps catch health problems early and can help you stay healthier over time.
Some services may not be covered, such as cosmetic procedures or treatments considered optional.
Coverage can vary by plan. If you’re unsure, ask your insurance company or your provider’s office before your visit.
Related: What You Need to Know About Medicare
Medications
How medications are covered depends on your insurance.
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Private insurance: Uses a list of covered medications (called a formulary). Generic medications usually cost less.
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Medicare: Prescription drugs are covered through Medicare Part D, which also uses a formulary.
For Oregon Health Plan (Medicaid) members: Most prescription medications are covered, often with no copay. Your provider and pharmacist can help choose medications that are covered by OHP.
Using Your Insurance at NHC
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Bring your insurance card to every visit
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Tell us if your coverage changes
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Ask about costs before your visit if you’re unsure
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Keep copies of bills and Explanation of Benefits (EOB) forms
If you don’t have insurance (or if your insurance doesn’t cover everything), NHC offers sliding fee discounts, payment plans, and financial support programs.
Related: Understanding the Oregon Health Plan and Coordinated Care Organizations
If You Get a Bill You Don’t Understand
Getting a medical bill can be stressful. Here’s what to do:
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Look at it carefully. Some statements are for information only.
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Call your insurance company if you’re unsure what you owe.
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Contact NHC. Our staff can help explain your bill and talk through payment options.
You have the right to understand your bill. Don’t ignore it, but try not to panic. Help is available.
Need Help With Your Insurance?
If you have questions or need support:
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Talk with NHC staff
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Ask about coverage before your visit
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Get help applying for or renewing the Oregon Health Plan
We’re here to help you understand your coverage and get the care you need.