Simplifying Health Insurance: Understanding Documents

Health care documents contain a vast amount of information, from medical records to billing statements, and can often be overwhelming or confusing to understand. That’s why we’re breaking down these common health care documents to help you understand what they mean.

EOC: Explanation of Coverage

An EOC is a document provided by an insurance company that outlines the details of your health insurance plan. Inside the EOC, you’ll find lots of helpful information such as:

What your insurance covers and doesn’t cover.

The EOC will tell you what your insurance will cover, like doctor visits, hospital stays, or medicine. It will also tell you if there are any things your insurance won’t cover, called exclusions. For example, maybe your insurance won’t pay for cosmetic procedures.

How to use your insurance.

It will explain how to make appointments with doctors, how to get medicine from the pharmacy, and how to file a claim if you need to get money back from your insurance. It might also have some extra rules and conditions that you need to know about.

How much you might have to pay when you use your insurance.

The EOC includes information on cost-sharing requirements such as deductibles, copays, and coinsurance. Read this blog for definitions of these terms.

EXAMPLE: The EOC details your plan’s deductible of $1,000, a copay of $20 for office visits, and 20% coinsurance for hospital services. Knowing these costs helps you budget for health care expenses and understand your financial responsibilities.

Your rights and responsibilities under their health insurance coverage.

It helps you know what you’re entitled to, like being able to choose your own doctor, and what you need to do to keep your coverage in good standing, providing accurate information to your insurance company.

EOB: Explanation of Benefits

An EOB is a document provided by an insurance company to you or your health care provider that explains how a claim for health care services was processed and paid.

The EOB typically includes details such as:

The date of service
The health care provider’s charges
The amount covered by insurance
Any deductible or copayment amounts
The portion of the claim that you may be responsible for paying

The EOB is like a receipt. It’s important to read your EOB carefully to make sure everything looks right and to understand what you might owe. That way, you can keep track of your health care expenses and make sure everything is handled correctly.

EXAMPLE: After a visit to a specialist, your EOB shows that the specialist billed $300, your insurance covered $240, and you owe a $60 balance. This total includes any copayments or coinsurance you need to cover.

SBC: Summary of Benefits and Coverage

The SBC is like a cheat sheet that gives you a quick overview of a health insurance plan so you can understand your options, compare plans, and select the plan that best fits your needs and budget.

The SBC includes information about deductibles, copays, coinsurance, out-of-pocket maximums, and coverage for common medical services. It also highlights any limitations or exclusions that may apply.

Formulary

A formulary is a list of prescription drugs that are covered by a specific health insurance plan.

The formulary categorizes medications into different tiers, which determine the level of coverage and cost-sharing for each drug.

Formularies are designed to promote cost-effective and evidence-based medication choices, and they may include both generic and brand-name drugs.

How do you use a formulary? You can consult your plan’s formulary to determine which medications are covered by your insurance and at what cost.

EXAMPLE: The formulary lists generic medications in Tier 1, which have the lowest cost-sharing, while brand-name drugs are in Tier 2 or 3 with higher costs. If you need a specific medication, you can use the formulary to determine its tier and expected costs, helping you make informed decisions about your prescriptions.

Simplifying Health Insurance: Common Terms

Navigating the world of health care can be complex, especially when faced with unfamiliar terms. If you find yourself wondering where to start or how these terms apply to you, begin by gaining a clear understanding of health insurance terminology. This will help you make informed decisions about your health care and ensure you are well-prepared for any medical expenses that may arise.

Claim

A request for payment submitted by a health care provider to an insurance company or third-party payer for services given to a patient.

It includes information like the patient’s diagnosis, treatment provided, and the cost of the services.
The insurance company reviews the claim and determines the amount they will reimburse the provider for the services.

EXAMPLE: After receiving treatment for a broken arm, the health care provider submits a claim to the insurance company. The claim includes details such as the diagnosis, the treatment provided (such as X-rays and a cast), and the cost of the services. The insurance company reviews the claim and determines the amount they will reimburse the provider for the services.

Deductible

The amount of money an individual or family must pay out of pocket for health care services before their insurance coverage begins.

EXAMPLE: If you have a health insurance plan with a $500 deductible, you will need to pay the first $500 of your health care expenses out of pocket before your insurance coverage begins. Once you meet the deductible, your insurance will start covering a portion or all of the eligible expenses, depending on your plan.

Coinsurance

A cost-sharing arrangement in health care where the insured individual is responsible for paying a percentage of the covered medical expenses, typically after meeting their deductible.

The remaining percentage is paid by the insurance company. It is a way to distribute the financial burden between the individual and the insurer.

EXAMPLE: Let’s say you have a health insurance plan with a 20% coinsurance rate. After meeting your deductible, if you receive a covered medical service that costs $100, you would be responsible for paying $20 (20% of the cost), while the insurance company would cover the remaining $80.

Copay

A copay (also called a copayment) is a fixed amount of money that an individual is required to pay out-of-pocket for a specific health care service or medication, typically at the time of service.

It is a form of cost-sharing between the individual and their insurance provider.

EXAMPLE: When you visit your primary care physician for a routine check-up, you may be required to pay a copay of $25 at the time of the appointment. This fixed amount is a form of cost-sharing between you and your insurance provider. Read more about Cost Share in the next section.

Cost-sharing refers to the division of health care expenses between the individual and their insurance provider.

It includes various out-of-pocket costs not covered by your health plan – such as deductibles, copayments, and coinsurance.
Cost-sharing helps distribute the financial responsibility for health care services and medications between the individual and the insurer.

EXAMPLE: Suppose you have a health plan with a $1,000 deductible, a 20% coinsurance rate, and a $30 copay for doctor visits. If you undergo a medical procedure that costs $2,000, you will first pay the $1,000 deductible out of pocket. After that, you would be responsible for 20% of the remaining $1,000 (coinsurance), which amounts to $200. Additionally, if you have a follow-up visit with a copay, you will pay the predetermined $30. These various out-of-pocket costs make up the cost-sharing between you and your insurance provider.

Medical Out‐of‐Pocket Maximum

The maximum amount an individual or family must pay for covered medical expenses each year, after which the insurance company covers 100% of the costs.

EXAMPLE: Let’s say you have a health insurance plan with a Medical Out-of-Pocket Maximum of $5,000. Throughout the year, you will be responsible for paying your deductible, copays, and coinsurance for covered medical services. As you pay these expenses, they will add up towards your out-of-pocket maximum. Once your total out-of-pocket expenses hit $5,000, your health insurance plan will take over and cover all eligible medical expenses. This means you will no longer have to pay any deductibles, copays, or coinsurance for the remainder of the coverage period.

RX Out‐of‐Pocket Maximum

The maximum amount an individual or family must pay for prescription drugs each year, after which the insurance company covers 100% of the costs.

EXAMPLE: Let’s say your health insurance plan has an RX out-of-pocket maximum of $1,500. Throughout the year, you pay for prescription drugs. Once your out-of-pocket expenses reach $1,500, the insurance company covers 100% of the costs for the rest of the year.

Premium

A premium is the amount of money an individual or entity pays to an insurance company for insurance coverage.

It is typically paid in regular installments – usually monthly or annually. It’s common for individuals to receive health insurance through their employer. In this case, the premium amount is typically deducted from their paycheck before they receive their net pay. This is known as a payroll deduction.
The premium amount is determined by various factors, including the type of insurance coverage, the level of coverage, the individual’s age and health status, and other risk factors.
Paying the premium ensures that the insurance policy remains active and provides the agreed-upon benefits and coverage.

EXAMPLE: You have health insurance coverage through your employer and the monthly premium for your plan is $200. Your employer offers a payroll deduction option. Therefore, your employer would deduct $200 from your gross salary each paycheck before you receive your net pay.

Health Network

A health network is a broad organization consisting of multiple facilities, such as hospitals, clinics, and specialty centers. These facilities are often located in different geographic areas and may be owned by different entities. A health network provides coordinated and integrated care to patients across various settings. Health networks often have a central administration that oversees the operations of all the facilities within the network.

Medical Group

A team of health care providers who collaborate to deliver comprehensive care, sharing resources and facilities for integrated services. These physicians may specialize in different areas, such as primary care, pediatrics, or cardiology. Medical groups can be independent or affiliated with a hospital or health network.