Insurance policies can be written with legalese that is difficult to comprehend, yet under the Affordable Care Act insurers must now provide consumers with a summary of benefits and coverage, sans legalese, that will enable them to easily compare plans during open enrollment periods.
An Explanation of Benefits (EOB) is a document that shows what health care providers cost, and what your plan covers – this statement does not serve as a bill but provides valuable insight.
Summary of Benefits and Coverage (SBC)
Under the Affordable Care Act (ACA), consumers are required to access and compare health insurance plans using a Summary of Benefits and Coverage document (SBC), which helps them compare policies. The SBC should follow a standard format and contain key details about benefits, cost sharing arrangements, limitations, exclusions and contact information – plus it must contain a Uniform Glossary with standard terms and definitions explained.
The SBC is designed to be simple for consumers to read and comprehend. All health insurers and plan providers, whether selling individual policies or being part of an employer-provided group plan, must offer this document for easy consumption by customers. Self-insured plans must follow a template in providing SBCs for their participants; additionally they may make them available in any participant’s native language upon request.
To simplify comparing plan options, the SBC provides “Coverage Examples.” These scenarios illustrate how cost-sharing, limitations and exclusions apply in common medical scenarios; examples such as simple fracture, Type 2 diabetes treatment and childbirth could all feature. Although the SBC provides costs as examples for comparison, their exact expenses will depend on individual circumstances.
Every Summary Benefits Summary must include a statement detailing how it fulfills Affordable Care Act requirements in terms of minimum essential coverage (MEC) and minimum value standards, and provide a reminder that it should only serve as a summary and refer back to policy documents, certificates or contracts of insurance for full details on coverage terms.
Consumers must receive an SBC when shopping for coverage either independently or through the marketplace, renew or change coverage plans, or enrolling in plans which experience material modifications. They can receive this document either electronically or on paper.
To access an SBC, visit the Marketplace website and locate it in each plan’s details section. Alternatively, download it as a PDF version by navigating your Marketplace account and expanding details section of view plan info; alternatively you may contact your health plan or insurer and request one be mailed directly.
Explanation of Benefits (EOB)
An Explanation of Benefits, or EOB, is a document used by health insurance providers and health insurers to explain medical claims. It details which charges were billed, what coverage your plan provides and any remaining payments from patients such as yourself. EOBs act as a bridge between healthcare providers, insurance providers, patients and patients alike and offer transparency throughout the billing process.
EOBs are typically sent out by healthcare providers after billing medical equipment purchased with insurance that was invoiced directly to a patient’s policy. Once sent by their insurance department, an EOB serves as confirmation that payment has been made and details what amounts remain due from them.
EOBs provide additional detail as to why certain charges aren’t being covered, often known as “not covered” amounts. This information can be useful in understanding why healthcare providers may have charged more than what your health plan pays; often this is due to your plan negotiating payment rates with providers. If a charge is unpayable and unclear why this is occurring, an EOB will list its reason and include either a code or note explaining this matter further.
Review your EOBs carefully in order to ensure that the healthcare services you are receiving are being billed correctly. If there are any discrepancies or mistakes in medical billing, reach out to both your provider’s billing department and/or insurance provider in order to rectify them immediately. By doing this, it will help prevent unexpected bills from surfacing as well as shorten the time between receiving an EOB and getting charged by healthcare providers. Reviewing your EOB can also help identify whether your insurance has applied any incorrect discounts or made an error in payment calculation, which could save money and prevent surprises when receiving your final bill from healthcare providers. Therefore, it’s always wise to keep EOBs until receiving final invoices from healthcare providers.
Evidence of Coverage (EOC)
Evidence of Coverage (EOC) documents provide comprehensive details regarding healthcare benefits included in a plan, its operation, associated costs and how people may file appeals. They outline one’s rights and responsibilities under such plans as well as ways to appeal.
An EOC is sent out annually to Medicare Advantage and Part D plan members, typically in late September with their Annual Notice of Change (ANOC) document and other related plan documents.
An EOC for any given health plan outlines any changes to costs and coverage that will take place in the new year, which is essential when selecting a Medicare plan.
EOCs provide an easy way to compare plans and see all your available options. Most EOCs will include a list of providers and pharmacies offering cost savings, while they may also contain instructions for filing an appeal or grievance with your plan should any decision or customer service issues arise.
An EOC can be a long and complex document, so it is wise to store a copy in a secure place for safe keeping. Furthermore, review it each year to check for changes and ensure the healthcare benefits meet your requirements.
Storage your Evidence of Coverage online provides many advantages. Not only can it allow easy access without needing to search through papers or worry where you put them, but you can use your computer’s search function quickly scan for key terms within it.
Some health plans only make their EOCs available after someone has joined and become a paid member, while some states mandate health plans provide EOCs before purchases to help buyers determine whether a specific plan meets their coverage needs. It’s always worth visiting their website to determine whether their EOC is posted.
Patient Billing Statement
After an insurance provider processes a healthcare service claim, patients receive a billing statement showing exactly how much was billed by each healthcare provider, how much was paid by insurance, what’s owed by patients out-of-pocket for visits, as well as any adjustments that have been made. It is essential that they review this statement to make sure the details are correct so they know exactly how much out-of-pocket they owe and can save time on phone calls trying to clarify or make payments.
Communication between healthcare providers and their patients is an integral component of care delivery; an EOB (Explanation of Benefits) gives patients assurance they are paying for what is actually being provided. Patients should keep both copies so they can compare how each one reflects on the actual charges for care provided.
As soon as you receive a patient billing statement, the first thing to check is its date of service and services and amounts billed. If the dates don’t correspond, this could indicate inaccurate records and should be addressed immediately. Also look at plan paid amount which shows how much of it has been covered by insurance as deductible or coinsurance payments by patients and any remark codes which might provide more detail on services provided such as codes or descriptions of treatments provided.
Idealistically, all patients would pay their bills promptly at the time of service and insurance carriers would make all required payments as expected. Unfortunately, medical billing processes are complicated with numerous variables that can contribute to discrepancies in payments. In order to minimize unpaid bills and decrease uncollected balances on time, healthcare organizations may wish to offer discount policies, sending statements frequently and offering multiple payment options in order to allow patients to manage their finances properly while clearing balances on schedule.