Joel Mekler | Medicare Moments: What is proof of coverage? | Lifestyles


Whichever health insurance plan you choose, you will be able to read a document that provides important details about your plan. It is commonly known as proof of coverage (EOC).

The COU is the legal contract between you and the health insurance plan. It is usually available from September and outlines the costs and benefits of your plan which will come into effect on January 1 of the following year.

Here are some additional frequently asked questions about how the EOC works.

•What plans does the COU cover? Medicare requires companies that offer Part C (Medicare Advantage) and Part D (prescription drug) plans to submit an EOC on an annual basis. Insurance companies typically send EOC documents in September because the Medicare Open Enrollment Period (OEP) runs from October 15 to December 7. This time frame gives a person enough time to consider any changes in plans. If a person doesn’t like the plan changes or wants to change plans, they can do so during the OEP. However, if they want to keep their current plan, they don’t have to do anything because their plan will automatically re-enroll them.

•How will I receive the COU? Are other materials supplied with the COU? Insurance companies will usually make these documents available in paper or online format. If for any reason a person misplaces or loses part of their EOC documents, they can request a new one from their plan provider. A person will typically obtain their Membership ID card along with their EOC from their Medicare Advantage or Medicare Part D plan provider. EOCs can be over 200 pages.

What are the key elements of an EOC? Included are the following:

•Costs: An EOC should include an explanation of policy costs, including monthly premiums, co-payments for doctor visits, and coinsurance percentages when a person seeks certain health services.

• Emergencies: An EOC should describe some of the cases that constitute a medical emergency and explain when the plan will pay for the care.

•In-network vs. out-of-network payments: The EOC should explain key cost differences (such as co-payments) when a person receives care from an out-of-network provider.

• Services Not Covered: Just as an EOC lists covered services. It will also list those that the plan does not cover.

• Directions to a List of Providers and Network Pharmacies: An EOC will indicate how a subscriber can find the list of providers and network pharmacies. A person usually gets the greatest cost savings by choosing in-network providers and pharmacies.

• Instructions for filing a grievance or appeal: An EOC will also include information on how to file an appeal if the plan denies payment for a particular service and how to file a grievance with the health insurance plan or drug insurance. A grievance is a complaint about plan services or provider customer service.

•Rights and Responsibilities of Plan Members.

•When does an EOC take effect? Most often, the EOC outlines potential benefit changes and blanket benefits that come into effect on January 1 of the following year. In other words, when a person receives an EOC notice in September 2021, they can expect the benefits outlined by the EOC to take effect on January 1, 2022.

Can I get proof of coverage for a plan I’m considering buying? Many health and drug insurance plans do not provide proof of coverage documentation until you have purchased a health insurance plan and are a paying member. However, if you need to know if a plan covers the benefits you need, you can try requesting the plan’s EOC document before enrolling. In addition, some state laws require health and drug benefit plans to make the EOC available to people considering purchasing a plan. So you should check with your state’s department of insurance to find out if your state has such a requirement.

• Is there a difference between an explanation of benefits (EOB), a notice of creditable coverage and proof of coverage? Yes. Your Explanation of Benefits (EOB) is a monthly statement that your Medicare Part D prescription drug plan (or Medicare Advantage plan) will send to you to explain your use of the Medicare plan year-to-date. The printed EOB document can be approximately 20 pages and your EOB Medicare Part D will show you a detailed list of your drug purchases, current expenses, and your progress towards Medicare plan limits or drug plan phases. (e.g. how close you are to entering or exiting your coverage gap or donut hole.

A creditable coverage notice specifically indicates whether the plan’s prescription drug coverage pays, on average, as much as standard Medicare prescription drug coverage. This information therefore helps the individual to decide whether or not to enroll in Medicare and must be sent to the relevant beneficiaries each year before October 15 of each year. There are a few forms of creditable coverage for Medicare. However, the most common form of eligible coverage is a group plan from a large employer.

Unless you have a large employer group health insurance plan, chances are you won’t have valid coverage for Part A and Part B. If you have either of the following forms of coverage, you will need to enroll in Part A and Part B when you first qualify to avoid late penalties: COBRA, Retiree Insurance, VA Benefits, Tricare, Federal Employee Health Benefits .

• I am enrolled in Original Medicare. Will I receive an EOC? No. If you only have original health insurance (Parts A and B), you will not receive a COU because your benefits, costs and co-payments are standardized.

•Can I access my plan’s EOC from the health plan search tool? Yes. Just go to the plan’s website.

•What other documents will my plan send me? In addition to the EOC form, you should also receive a document called the Annual Notice of Change (ANOC). The ANOC includes information about changes to a plan’s cost, coverage, and service area. It is usually an 8-10 page document. In addition to the ANOC, you will be able to access your plan’s formulary (a list of covered medications) and provider directory online. Use these documents to determine if you want to change your health or drug insurance plan or keep it as is for another year.

(Joel Mekler is a Certified Senior Counselor. Send your Medicare questions to him at [email protected])

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