How Are Payments Determined For My Care By A Medigap Plan?

An EOB is an Explanation of Benefits and is the insurance carrier’s method of summarizing the details of the claim submitted and explaining the particulars of reimbursement. Although each payer can define benefits in its own endearingly idiosyncratic way, you can expect to find essentially the same information on any EOB:

1) Patient’s name and relationship to insured.

2) Services rendered, dates of service and total charges.

3) Exclusions and special (not sarcastic, although it may seem that way) remarks about the reason for dental, suspended claims, or additional information needed.

4) Amount of total charges covered.

5) Deductible amounts due for each service.

6) Percentage of allowed balance paid.

7) Required provider adjustments or other deductions.

That Medigap Plan

Many purchase supplemental health-care insurance to cover co-insurance fees. The supplemental coverage is referred to as Medigap because it fills in the gaps between what Medicare pays and what it does not. A Medigap Plan is sold and administered by private carriers, but it is regulated by the government. There are ten standard plans, lettered A through J (one through ten would be too easy), and insurers are not allowed to sell more than these ten plans. Plan A is the basic package and must be offered, although, of course, purchasers can go with the upgrade of their choice.

Medigap Ingredients

A Medigap Plan covers all, or nearly all, co-insurance amounts. Some cover deductibles. Other pay doctor charges that exceed the approved amount, and still others take care of otherwise noncovered services such as prescription drugs and preventive screenings (the health-care kind, not the Hollywood movie kind).

Dr. Whosit Example

Let us say that Dr. Whosit is accepting Medicare assignment. Let us say that the patient’s Medigap policy is sent for processing and the claim is processed and a check sent to the provider of the services. Even keener, some Medigap insurers have cross-over contracts with Medicare. In these cases, Medicare will automatically forward claims even if the doctor does not accept assignment.

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