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 being 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.
VEBA Resources
MyVEBA Portal: Use the MyVEBA app or online portal for your benefits information and updates. Download the app for Apple or Android, or visit the MyVEBA Portal for desktop access.
Benefit Contacts: For assistance with specific carrier benefits or issues, such as claims or coverage details, visit vebaonline.com/benefit-contacts to contact them directly.
Get Support: The VEBA Advocacy Team is here to assist with health care navigation, including appointment scheduling and quality of care. Call 888-276-0250 or visit vebaonline.com/contact for assistance. For urgent requests, use the “Urgent” box on the contact form.
If you find this blog helpful in understanding health insurance terms, be sure to check out the other blogs in this series for more in-depth information and insights into the world of health care.
