A Medicare Advantage Explanation of Benefits (EOB) is a statement from your plan that lists the services your providers billed, what the plan allowed and paid, and what you may owe. It does the same job a Medicare Summary Notice does for people with Original Medicare. Use it to check your doctor and hospital bills: the amount you owe a provider should match the "you may owe" or "your share" amount on the EOB.
What is an Explanation of Benefits from a Medicare Advantage plan?
If you're in a Medicare Advantage plan (sometimes called Part C), a private company approved by Medicare handles your Part A and Part B coverage. Because the plan pays your claims, Medicare doesn't send you a Medicare Summary Notice for that care. The plan sends its own statements instead.
Each plan designs its own EOB, so the layout and wording vary from one company to the next. Most plans mail one after you have claims, and many also post them in your online member account. If your plan includes drug coverage, Medicare.gov says you'll get a drug-claim EOB each month you fill a prescription. Some plans combine medical and drug claims on one statement; others send them separately.
Most EOBs have "This is not a bill" printed on them. Bills come from your providers.
What are the main sections on a Medicare Advantage EOB?
Labels differ by plan, but you'll usually find these parts:
1. Member information. Your name, member ID, and the statement period. Check that it's you, especially if two people in the house have the same plan.
2. Claim summary. A short overview: how many claims were processed, the total billed, the total the plan paid, and the total you may owe.
3. Claim details. One block per visit or provider, with lines for each service. Common columns include:
- Date of service.
- Provider name.
- Service description and code. Often a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code you can match to an itemized bill.
- Amount billed (or provider charges). The provider's full price. This usually isn't what you owe.
- Allowed amount (or plan-approved amount). The amount the plan agreed to pay for that service under its contract with the provider.
- Discount or plan savings. The difference between billed and allowed. An in-network provider generally can't bill you for this.
- Plan paid. What the plan sent the provider.
- Your share (or what you may owe). This can be split into deductible, copay, and coinsurance.
- Not covered. Amounts the plan didn't cover, with a reason code.
4. Remark or reason codes. Short codes beside some lines, explained at the bottom or on the back. These tell you why something was denied, reduced, or paid differently.
5. Year-to-date totals. Many EOBs show how much you've paid toward your deductible and toward your plan's yearly out-of-pocket limit.
6. Appeal rights. Instructions and deadlines for disagreeing with a decision.
What is the out-of-pocket limit on my Medicare Advantage EOB?
Medicare's "Understanding Medicare Advantage Plans" booklet says plans have a yearly limit on what you pay for covered Part A and Part B services. Once you reach your plan's limit, you pay nothing for Part A and Part B services the plan covers for the rest of the year.
The limit is set by each plan and can include a separate limit for out-of-network care. Your EOB's year-to-date section can show how close you are. Your plan's Evidence of Coverage lists the exact amount.
If you've already reached the limit and a later EOB still shows you owing a copay for a covered service, call the plan.
How do I match my EOB to my medical bills?
Put the EOB beside the bill from the same date and provider. Then check:
- Is the date of service the same?
- Is the provider the same?
- Does the bill match "your share" on the EOB? A bill for the full billed amount, or for the "discount" amount, is a red flag for an in-network provider.
- Did you already pay a copay at the visit? Make sure it was credited.
- Is every service on the bill also on the EOB? If the provider bills you for something the plan never processed, ask whether they submitted it.
- Do you recognize every service on the EOB? Services you didn't get should be questioned.
Wait for the EOB before paying a large bill when you can. Providers sometimes send a statement before the plan has finished processing.