Shasta-Trinity Schools Insurance Group

EOB/Benefit Training

AgendaKey terms to know

How to read your Explanation of Benefits (EOB)

Real world claims example/comparison

Comparing HMO, PPO, and HDHP plans

Key TermsParticipating Providers: Doctors, hospitals,

and other health care providers/facilities that have contracted with Anthem Blue Cross to provide services at a discount rate

Non-Participating Providers: Doctors, hospitals, and other health care providers/facilities that have NOT contracted with Anthem Blue Cross, and have not agreed to provide services at a discounted rate

Key TermsCalendar Year Deductible: This is the amount that you are

responsible for paying each calendar year before your plan begins to make payment for most services you receive. The Calendar Year Deductible does not apply to/is waived for certain services (ie., office visits, preventive care services)

Out-of-Pocket Maximum: This is the maximum amount of Coinsurance that you will have to pay for services you receive during the calendar year. The following services do not apply toward the satisfacton of the Out-of-Pocket Maximum: Calendar Year Deductible, Copayments, and Amounts Not Allowed (Non-Participating Providers). After reaching the Out-of-Pocket Maximum, you are still responsible for paying Copayments (where applicable) and any Amounts Not Allowed.

Key Terms Copayment: A flat dollar amount that you are

responsible for paying for certain services (ie., office visits, physical therapy, chiropractic). The Calendar Year Deductible is waived for some services (ie., office visits). In addition to the copayment , you are also responsible for Coinsurance, where applicable.

Coinsurance: This is the percentage that you are responsible for paying for services you receive, after you have satisfied your Calendar Year Deductible (where applicable) and paid any applicable Copayment

Key TermsTotal Billed Amount: The amount billed by a provider for

services rendered

Patient Savings: For services rendered by a Participating Provider, this is the amount that is discounted from the providers Total Billed Amount. You are not responsible for this amount

Amount Not Allowed: For services rendered by a Non-Participating Provider, this is the difference between the provider’s Total Billed Amount, and Anthem’s allowed amount. You are responsible this amount when you receive services from a Non-Participating Provider.

Example Claims Scenario*assumes Premier PPO Wellness plan

Service

Amount Billed

Anthem/Provider Contracted Rate

Deductible Co-pay

20%Coinsurance

80%Anthem Pays

Office Visit

$125.00 $100.00 $0.00 (waived for office visits)

$25.00

$15.00 $60.00

Strep Test

$25.00 $12.00 $12.00 $0.00 $0.00 $0.00

Blood Work

$650.00 $325.00 $238.00 $0.00 $17.40 $69.60

Total Patient Responsibility for this date of service: $307.50

Claims AnalysisSummary:

Cardiac incident (chest pains) resulting in visit to urgent care, Ambulance transport, ER admit for overnight hospital stay.

TOTAL CHARGES

Anthem Discounted

RateUrgent Care Office Vist and Service $225.00 $127.59Ambulance Transport $2,344.21 $1,447.21ER Physician Services $580.00 $396.19Radiology Services $274.00 $254.00ER and Inpatient Hospital Services $20,819.42   $7,940.00TOTALS $24,242.63 $10,164.99

 Premier (80/20)  

Standard (70/30)  

Consumer Choice (70/30)   Uninsured

Urgent Care Copayment $25.00   $25.00   N/A   N/ADeductible $250.00   $1,000.00   $3,750.00   $0.00Co-Insurance $1,978.00   $2,742.00   $2,749.50   $24,242.63*Total Member Out of Pocket Expense: $2,253.00   $3,767.00   $6,499.50   $24,242.63

*Assumes Wellness Incentive Credit, Family DeductiblePremier (80/20)  

Standard (70/30)  

Consumer Choice (70/30)   Uninsured

Annual Premium (Tiered/Family) $16,476.00   $15,912.00   $14,808.00   0Total Annual Expenses: $18,729.00   $19,679.00   $21,307.50   $24,242.63

Questions? Problems? Who do you call?1st: Anthem Customer Service:I’m not sure my claim was processed/paid correctly.Who are preferred providers in my area?Is this procedure/service covered on my plan?Have I met my deductible?

2nd: Shasta Trinity Schools Insurance Group:Claims issues that were not resolved to your

satisfaction with Anthem Customer Service.

Comparing Plan TypesHMO PPO High Deductible Health

Plan (HDHP) PPO

Referral required for specialists

Yes No No

Non-Participating Providers Covered?

No Yes Yes

Deductible No Yes Yes

Deductible applies toward Out-of-Pocket Maximum

Not Applicable

No Yes

Copayments/Coinsurance applies toward Out-of-Pocket Maximum

Yes Copayments: NoCoinsurance: Yes

Yes

Prescription Drug Copayments apply toward Out-of-Pocket Maximum

No No Yes