Dear Marci,
I have a Medicare Advantage Plan. I just received a document listing costs for all the health care services I received last month. There are several different columns that show different amounts of money—do I have to pay for everything on here?
-Paul (Mobile, AL)
Dear Paul,
It sounds like the document you are looking at is your Explanation of Benefits (EOB). An EOB is the notice that your Medicare Advantage Plan or Part D prescription drug plan typically sends you after you receive medical services or items. EOBs are usually mailed once per month, and some plans give you the option of accessing your EOB online.
You only receive an EOB if you have a Medicare Advantage Plan or a Part D prescription drug plan. An EOB is not the same as a Medicare Summary Notice, which you get if you have Original Medicare.
It is important to know that an EOB is not a bill. Your EOB is a summary of the services and items you have received and how much you may owe for them. It tells you how much your provider billed your plan, the approved amount that your plan will pay, and how much you have to pay to the provider. While all EOBs provide the same information, the layout and other specifics may vary by plan.
The amount that you are responsible for paying should be included in the “Your Share” column of the EOB. Remember that the EOB is not a bill. If you still owe anything, you should receive a bill directly from your doctor or other provider who performed the service. There are several reasons that you might be responsible for a bill:
- You have not yet reached your deductible, the amount that you must pay for health care expenses out of pocket before your health insurance plan begins to pay. Once you reach your deductible, your plan will begin paying for part or all of the covered services.
- You owe a copayment, or copay, which is a set amount that you pay each time you receive a service. You may have already paid this when you were leaving the doctor’s office.
- You are responsible for a coinsurance, which is a percentage of the cost of an item or service you received.
- Your plan is denying your coverage. If you are denied coverage for a service that you believe should have been covered, you should appeal this decision.
- The final page of your EOB should include instructions for appealing this decision. For more assistance with appealing, you can contact your SHIP. If you don’t know how to contact your SHIP, you can call 877-839-2675 or visit www.shiptacenter.org.
If you have any questions about your EOB, you should call your Medicare Advantage Plan using the phone number on the back of your insurance card. You should review your EOB to make sure it is accurate, and that you actually received the services and items on the dates of service listed. If there is any incorrect information (like, for example, if your EOB lists a service that you did not receive), you should call the listed provider to check if their office made a billing error. If you suspect that a provider is intentionally billing your Medicare Advantage Plan for services they did not deliver, that someone is using your Medicare number or card, or that some other form of fraud is occurring, you should contact your local Senior Medicare Patrol (SMP). Your SMP will be able to help you identify fraud and, if necessary, report it to the proper authorities. To contact your SMP, call 877-808-2468 or visit www.smpresource.org.
After you have reviewed your EOB, you should keep it somewhere safe. You may need it in the future to prove that payment was made if a provider’s billing department makes a mistake or if you claimed a medical deduction on your taxes. If you lose your EOB or need a duplicate copy, you should contact your Medicare Advantage Plan.
-Marci