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Vol. 13, Issue 25  • December 15, 2014

How do I read my Explanation of Benefits notice?

Dear Marci,

I have a Medicare Advantage plan, and I get two notices from my plan every month. Both are called Explanation of Benefits. It seems like one is about my health care services, and one is about my prescription drugs. These statements have a lot of information, and I sometimes find them confusing and hard to read. What are they and why am I getting two different ones?

- Vivian (Buffalo, NY)

Dear Vivian,

If your Medicare Advantage plan includes prescription drug coverage, you should receive two kinds of Explanation of Benefits notices: one that explains your recently received health care services, and a second kind that summarizes your prescription drug usage in the past month.

Keep in mind that your EOB is not a bill; it simply states the health care services you have received over a period of time and the amount you have paid or should expect to pay for them.  You will receive a separate bill directly from your provider for any amounts you owe them. Read your EOB to verify that you received all health care services listed, and to check that you have paid the proper amounts to your provider. If you overpaid your provider, contact your plan to correct that mistake.

Be sure to note whether or not the EOB has denied payment for any health care services. The EOB should either contain instructions for filing an appeal, or instruct you to read your “Notice of Denial of Payment,” which can be mailed along with your EOB, or separately.

Your EOB for prescription drugs must always come on a monthly basis. The prescription drug EOB will list what the plan has paid for a prescription, and what you paid for that prescription at the pharmacy. It will also include what you have paid out-of-pocket for prescription drugs for the year, as well as your Part D coverage phase—which can be deductible, initial coverage, coverage gap, or catastrophic coverage. If your plan denies payment for your prescription, you should receive a notice immediately at the pharmacy counter. This notice gives steps for starting an appeal. For more information about denials and appeals for prescription drugs to your Part D plan, click here.

The EOB is similar to the Medicare Summary Notice (MSN) that people with Original Medicare, the traditional Medicare program administered directly by the federal government, receive every three months. However, if you have Original Medicare and a stand-alone Part D plan, you will receive an EOB from your Part D plan for prescription drugs that you have filled each month.

-Marci

Health Tip
An evaluation of cognitive abilities by a doctor can help to identify early signs of dementia, but many Americans never receive screenings. A recent study from the American Academy of Neurology found that in a study of 300 people with dementia aged 70 and over, 55 percent had never had their memory and thinking abilities screened by a doctor. Early screening and diagnosis of dementia can help to improve someone’s quality of life and promote longer-term independence. The study also found that married people were twice as likely to undergo dementia screenings as single people, but that the number of one’s children did not impact whether someone received a screening or not.

For more information about the study, click here. To read the full study and its findings, click here. To read more about dementia and cognitive and memory screenings, click here for information from the Alzheimer’s Association.

Need to Know
If you received a notice in the mail that your Medicare Advantage plan is ending on December 31, 2014, you have a Special Enrollment Period to enroll in a new Medicare Advantage plan, or switch to Original Medicare with a Medigap policy and a stand-alone Part D plan for prescription drug coverage. To avoid any gaps in coverage, make your coverage decision by December 31, 2014.

To read more about your options, click here. If your Medicare Advantage plan is ending and you receive Extra Help, click here.

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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