Sometimes the messaging around your benefits—especially your medical plan—can feel like a foreign language. Consider this glossary to be your translator!
Allowed amount
The maximum amount used to determine the cost of covered health care services. May also be referred to as "allowable charge," "eligible expense," "payment allowance," or "negotiated rate."
Balance billing
A bill for the difference between the amount the plan reimburses for covered services—the allowable amount—and what an out-of-network provider charges. You do not have to pay this amount if you see an in-network provider.
Brand-name drugs
Drugs approved by the FDA that are under patent to the original manufacturer. They’re only available under the original manufacturer’s brand name.
Claim
A provider’s request to your plan administrator asking to be paid for a service you’ve received.
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA), which allows you and your enrolled dependents to continue group health benefits after a qualifying life event. You pay for the full cost of coverage extended under COBRA.
Coinsurance
A form of cost sharing in which you and the plan each pay a set percentage for covered services and prescription drugs.
Copay
A flat dollar amount you pay at the time a covered service is rendered or when you fill a prescription for medication. When a copay applies, you’re typically not responsible for any coinsurance or deductible.
Deductible
A flat dollar amount you pay for covered services and prescription drugs before the plan begins to share the cost of those services.
Evidence of insurability (EOI)
A process used to qualify you for certain amounts of group life insurance coverage. It often involves a questionnaire but can also include urine and blood tests, along with a physical exam, as requested by the insurance carrier. May also be referred to as "proof of good health."
Exclusive provider organization (EPO)
A medical plan in which services are covered only if you go to doctors, specialists, and/or hospitals in the plan’s network (except in an emergency).
Explanation of benefits (EOB)
A statement you receive from the claims administrator after your claim is processed. The EOB provides information about how your claim was paid, including the amount covered by the plan, and how much you owe or will be reimbursed.
Flexible spending accounts (FSAs)
Special tax-advantaged spending accounts you can use to pay for eligible health care and/or dependent care expenses.
Formulary
The list of prescription medications approved for coverage by the health plan. The formulary is updated regularly and is designed to assist physicians in prescribing drugs that are medically necessary and cost-effective. May also be referred to as "prescription drug list."
Generic drug
A drug approved by the FDA as a therapeutic equivalent to a brand-name drug, with the same active ingredient as the brand-name version but at a lower cost.
Health Savings Account (HSA)
Special tax-advantaged savings account that pairs with a high-deductible health plan. You save on taxes three ways with the HSA: no taxes on your contributions (including those from Autodesk), no taxes when you use the money to pay for eligible medical expenses, and no taxes on interest earned on your account.
In-network
The facilities, providers, and suppliers your health plan has contracted with to provide covered health care services at negotiated rates. May also be referred to as "network."
Maintenance medications
Drugs prescribed to treat chronic health conditions—such as asthma, diabetes, high blood pressure, or high cholesterol—and taken on an ongoing, regular basis to maintain health.
Non-network
Facilities, providers, and suppliers not contracted with your health plan. Some plans provide non-network benefits, typically with higher coinsurance and balance billing to the member. May also be referred to as "out-of-network."
Non-preferred
A category used in some formularies for prescription drugs that generally have higher copays or higher coinsurance than preferred brand-name drugs.
Open Enrollment
A specific period occurring once a year when you can enroll in or make changes to your benefits elections without experiencing a qualifying life event.
Out-of-pocket maximum (OOPM)
The most you’ll be required to pay in a calendar year for deductibles, copays, and coinsurance. Once you reach the OOPM, the plan pays 100% of eligible expenses. Note: Health insurance premiums and charges in excess of the maximum allowed amount do not count toward the annual OOPM.
Preauthorization
Advance approval from the insurance company that may be required for certain services to be covered by the plan. Preauthorization is obtained by you or the provider contacting the insurance company. May also be referred to as "prior authorization."
Preferred provider organization (PPO)
A medical plan that allows you to choose any provider you wish. However, using network providers and hospitals is more advantageous, because you’ll pay lower coinsurance on negotiated rates that are often significantly lower than those charged by non-network providers. You also avoid any balance billing. You can select most providers without a referral.
Preventive care
A set of health care measures that help prevent disease and detect health concerns early, such as annual physicals, mammograms, and colonoscopies. Based on your age and gender, your medical plan provides preventive services at no cost to you if you visit a network provider, and claims are correctly coded as preventive. Follow-up testing for a diagnosed medical condition is generally not covered as preventive.
Qualifying life event
A life event that allows you to make certain changes to your insurance coverage. You must request any changes to coverage within 31 calendar days of the date the event occurred (except for birth events, for which you have 60 calendar days to make changes).
Specialty medications
Drugs that are used to treat complex or chronic conditions that usually require close monitoring, such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancer, and other conditions that are difficult to treat with traditional therapies. Specialty drugs may require preauthorization.
Summary of Benefits and Coverage (SBC)
A snapshot of a health plan’s costs, benefits, covered health care services, and other features that are important to members. SBCs also explain health plans’ unique features, like cost-sharing rules, and include significant limits and exceptions to coverage in easy-to-understand terms.
Summary Plan Description (SPD)
A guide that details the benefits covered by the plan and explains how the plan works.