The New Year and Medicare Paperwork:: Part 2 — Medicare Advantage Plan Notices

If you are covered by a Medicare Advantage plan, an Explanation of Benefits notice comes from the carrier which is providing your Medicare Advantage plan.

You will probably be familiar with the EOB from your days when you were covered under a commercial health plan. What is a bit different here is that the network providers you see while on a Medicare Advantage plan are contracted with the carrier, and they present their billings to that carrier exclusively.

The Medicare coverage contract with the carrier is Medicare specific and as long as the plan covers the treatment or service, there should never be an instance where you have to worry over billings from your providers.

[ed. note*** Keep in mind, however, that if the network provider extends services not covered under their contract, there might be an issue with respect to reimbursement. To get the most specific information on specific coverages, please review the Evidence of Coverage document you should have received for the coverage year. If you didn’t get one, let me know and I can get you an electronic version of the EOC for your review.]

An exception to an earlier statement might be if you have a PPO Medicare Advantage plan, and you have seen an out-of-network provider. In such case, the provider will have had to agree to billing the carrier. If the provider has costs greater than the carrier’s contractual payments for the same services, the situation should be covered under Colorado’s network adequacy laws, where the carrier is responsible for reconciling payment to the provider. This is a situation, nonetheless, that will require your vigilance.

The EOB lists the services you’ve received and you will notice that costing is listed by amounts that are paid by the carrier and the amounts that you owe (ie. copays, coinsurances). It should also indicate if you’ve already paid for any cost-shares. These notices come out monthly, when you have received medical care.

Once again, review the EOB, which is organized by the date of service, to insure that nothing is included there that you did not receive. Notify me or the carrier if you notice discrepancies and we will work to correct them.

This EOB is the best place to track where you are with respect to the annual out-of-pocket maximum under the Medicare Advantage plan than you have. Not unlike a checking account statement, however, it will only be current as to the claims made to the plan before the end of the monthly close out. If you are receiving frequent or regular/chronic care, the most recent visits may not appear on this EOB. Moreover, if the provider is somewhat lack in filing their claims, there could also be delays. It is up to you to keep an eye on this EOB.


Do you have family, friends or co-workers that are approaching Medicare age?

If you have a club, association or a location near you that you would like for me to arrange a Medicare/Social Security presentation, please let me know and I will be happy to make arrangements.

Call R Allan Jensen at 303.912.5490.
Posted:: Centennial CO 1/21/2015