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Vol. 15, Issue 7 – April 4, 2016
What is an Explanation of Benefits? Dear Marci,My Medicare Advantage Plan sent me a notice called an Explanation of Benefits. What is this notice, and how do I make sense of it?

– Louis (Cape Elizabeth, ME)

 

Dear Louis,

An Explanation of Benefits (EOB) is a notice that your Medicare Advantage Plan typically sends you after you receive health care services or items. EOBs are usually mailed once per month and may be available online. An EOB is not a bill; it is a summary of services or items you received.

Each plan formats its EOB differently, but in general your EOB should tell you:

  1. How much your provider billed the plan.
  2. How much your plan will pay. This amount may be different from the amount your provider billed. This is because plans have negotiated rates with providers that work with the plan, and the plan will only pay up to its approved amount for services.
  3. How much you may owe. This column may be called “patient responsibility.” As noted, the EOB is not a bill. It is simply informing you of the amount you may owe. Your provider will send you a bill for the services you received. You may be responsible for a bill if you owe a copayment or coinsurance, have not yet reached your deductible, or if your service was denied coverage.

In addition to the information it provides, an EOB is important because it is the notice that allows you to begin an appeal. An appeal is when you ask your health insurance plan to reconsider its decision to deny coverage of a service or item you received. If your EOB shows that your plan did not approve payment or coverage for a service you received, you can appeal. Look for footnotes on the EOB that explain why the service was denied. This will be useful in writing your appeal.

There should be instructions about how to appeal included on the last page of your EOB, and you will need to start your appeal within 60 days of the date of  the notice. If possible, it is a good idea to ask your provider to help with the appeal by including relevant medical records and a letter of support.

EOBs contain important information about your appeal rights and the services you received. You should read these notices carefully and contact your plan and provider if you have any questions, or if you see services listed that you don’t recognize.

– Marci

Health Tip
Protein is a key nutrient that helps build muscle and provide energy. The National Institutes of Health (NIH) recommends 5.5 grams of protein per day for someone on a 2,000 calorie/day diet. Many people may think of getting protein from meat, poultry, and fish, but there are many other options for those who wish to add variety to their meals. Foods like beans, nuts, and tofu all contain protein and can be substituted for meat in many dishes. In fact, plant-based proteins can be healthier alternatives to certain meat products. For example, beans are low in saturated fat and contain many nutrients.  Check out some of the recipes below for ideas about how to add beans or tofu to one of your meals this week.

Need to Know
Introducing a brand-new Medicare InteractiveThe Medicare Rights Center is excited to share with you our brand-new Medicare Interactive (MI) website. We encourage you to create a free MI profile today!Some features include:

  • New and improved resources. MI’s new design and features ensure you’ll find the answers you need quickly– through smart links to relevant MI pages and case examples, a roll-over glossary, and other helpful resources.
  • MI Pro: A web-based curriculum. For those looking to dig deeper into Medicare, please check out the Medicare Interactive Pro (MI Pro) learning curriculum, which will evolve further in the coming months. As an MI Pro subscriber you’ll access exclusive in-depth Medicare content, quizzes, and printable learning tools.
  • Free Medicare Interactive profiles. By creating your free MI profile, you can bookmark your favorite pages, manage newsletter subscriptions, access free exclusive links/downloads, and receive notices about key Medicare dates. As an initial thanks for registering you’ll receive a welcome e-packet from Medicare Rights, complete with our New to Medicare Guide. 

Dear Marci is a biweekly e-newsletter designed to keep you — people with Medicare, social workers, health care providers and other professionals — in the loop about health care benefits, rights and options for older Americans and people with disabilities.

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