Health insurance comes with a flood of paperwork, and much of it includes unfamiliar words and phrases. There are four main types of documents you'll receive. You will receive the first two -- the summary of benefits and coverage, and the uniform glossary -- when you sign up for a health plan and each year when you renew your plan. The second two -- an explanation of benefits, or EOB, and medical bills -- you receive when you use your insurance.
The guidelines below will help you understand the purpose of each document and why it's important. This will help you spot billing mistakes and help you learn how your insurance works and what charges you have to pay.
1. What is the summary of benefits and coverage?
The Affordable Care Act requires all private insurers and employer health plans to provide a list of what benefits are included in the plan and the details of their coverage. The summary must use plain language that is easy for the average reader to understand. A sample form can be found here.
2. Why is the summary of benefits and coverage important?
In addition to listing your benefits and the coverage details, the summary includes information on:
- Your appeals and grievance rights and procedures
- Your rights to keep your insurance coverage or get replacement coverage if your insurance company stops offering insurance in your area.
- Instructions for how to get information in other languages
You should keep your summary of benefits and coverage handy so you can refer to it when you need medical services and want to know in advance how your care will be covered. It’s also helpful afterward when you get an explanation of benefits or a bill.
3. What information is on the summary of benefits and coverage?
The summary should include:
- Your deductible
- Your cost-sharing amounts -- the portion of the treatment or service that is your responsibility
- Your out-of-pocket limit
- Whether the plan has a network of providers you must use and the difference in cost-sharing if you use an out-of-network provider
- Whether you need a referral to see a specialist
- Any services or treatments the plan does not cover
- The plan’s coverage for common medical events like visits to primary care doctors, lab tests, and hospital stays
4. What is a uniform glossary of terms?
The glossary defines some of the most commonly used insurance terms in plain language. These terms include co-insurance, balance billing, appeal, and medically necessary. Your plan will have its own glossary, but you can see an example here.
5. What is an EOB?
Your insurance company sends you an explanation of benefits when it gets a request for payment from one of your health care providers (such as doctors, specialists, laboratories, hospitals, and clinics). An EOB is not a request for payment from you. You do not have to make any payment when you receive an EOB (see “bill” below). The EOB describes the medical treatment you got from the provider. Note: Some HMOs do not provide an EOB because they pay their providers a monthly fixed fee for your care.
6. Why is an EOB important?
This statement is your chance to review the money that's being paid for your health care. By checking your EOB, you can track how much your health care costs. You also can look for billing errors. EOBs give you the chance to question any payment that doesn't look right.
7. What information is on an EOB?
It should show:
- Your name and address
- Your policy number
- The name of the patient -- you or the person who got treatment
- The name of the doctor who provided the care
- The date of the service
- The cost of the service
- How much your insurance paid
- How much you owe for this visit
Your EOB also should have a short description of the care the patient got. If part of the care was not covered by your insurance, the EOB will explain why.
8. What should you check on every EOB?
- Whether you saw the doctor on the date listed
- Whether you got the services the provider claims to have performed
- Whether you are being billed more than once for the same service
- How much the insurance company paid toward the total bill and whether that matches your plan's benefits
- Whether you have to pay any or all of the bill because you haven't met your deductible
- If the insurance company rejected any of the claim and the reason why
9. What is a bill?
A bill is a request for payment from your health care provider. It will show how much you owe for your medical care after your insurance has paid its share.
10. What information is on a bill?
It should include:
- The name and address of the medical provider
- The date of the bill
- Your name, address, and account number
- The date of treatment
- The patient's name if it's not you
- A description of the medical service that was given
- How much the service cost
- The amount your insurance paid for the service
- The amount that you owe
- Other unpaid charges that you might have had before this bill
11. How can you check to see if you're being billed correctly?
First, see if you got an EOB from your insurance company about the services in your medical provider's bill. This is very important, because some doctors and medical facilities will send you a bill before your insurance company has paid it.
These early bills show the full cost of the service, not just your share. You only have to pay the amount still owed after your insurance company has paid its share.
If you get an EOB from your insurance company, you should hold it side-by-side with the bill to compare:
- The dates of the medical care
- The services the provider is billing for
- The amount the insurance company has agreed to pay
- The amount you owe
12. What if you have questions about a bill?
Call your health care provider's office if you have questions about the dates of your medical care or the description of the services or care.
Call your insurance company with any questions about payment. For instance, you might want to find out why your insurance didn't cover a charge or paid only part of the amount.
13. How can you fight a bill?
You have the right to appeal any decision by your health insurance company. The Affordable Care Act requires that health plans provide an internal appeals process. This lets you challenge claims that your insurer rejected. You also can find out more about why they were rejected.
If your internal appeal is denied, you also have the right to an independent external review. Your insurance company should send you information about how to file an external appeal and the contact information for the organization that will handle your review. Most states have their own external review process, usually administered by the department of insurance. Several states use an external review process administered by the federal Department of Health and Human Services. You can find out here whether your state is one of those. If the external review process is federally administered, you can file your appeal here. You may also request an expedited external review if the standard timeframe (45 days) would put your life, health, or ability to maximum function in danger.
Keep copies of all your bills and EOBs. Also keep any letters from your provider or your insurance company about a dispute. Write down the name and phone number of every person you talk with about your bill. Include the date of the conversation. These records will be very helpful when it comes time to argue your case.
14. Where can you get help fighting a bill?
Some states have consumer assistance programs within the state insurance office. You can go to the Center for Medicare and Medicaid Services to find out what help is available in your state. You also can get information and assistance about fighting a medical bill from:
- U.S. Department of Health & Human Services: 888-866-6205
- Patient Advocate Foundation: 800-532-5274
- Cancer Legal Resource Center (CLRC): 866-843-2572
If you have health insurance through your employer, you may want to check with your human resources department to find out if they offer any assistance.