When people get enrolled into Medicare programs, they are mailed many different pieces of information about their benefits. After receiving so many mailings about different things, some beneficiaries begin to stop reading their mail. This is a mistake for anyone to make. There is critical information mailed to members each month, such as an explanation of benefits.
An Explanation of What?
Most Medicare beneficiaries don't know what an explanation of benefits is or why it's important. An explanation of benefits is a notice that is sent out to beneficiaries every month to explain how their Medicare benefits have been used. This is something that is especially important with a Medicare Part D prescription drug plan. Anytime a person's Medicare Part D prescription insurance card is used to get medications, there is a record created and kept on file. Centers for Medicare and Medicaid Services require insurance providers that offer Part D prescription plans to mail a copy of those records to their members. This is a mandate that can't be ignored, it has to happen.
On an explanation of benefits, there is specific information that should be listed. This information is very important for patients to review. This information is specific to their benefits and what they have available to them.
What Should I Check?
When reading a Medicare Part D prescription drug plan EOB, explanation of benefits, members should ensure their demographics are correct. This means their name should be spelled correctly, their address is correct as well as their patient number. Not only should the member's demographics be correct, their provider's information should also be listed correctly. If there are any errors with this information, it could be a sign that information is recorded incorrectly about the member with their Part D prescription plan provider or Medicare. This should prompt a call to their insurance provider.
The next piece of information that should be reviewed is the information stating how much the out of pocket expenses were for the month, the accumulated total out of pocket expense as well as the total drug cost for the month and the accumulated total drug cost for the year. These sets of numbers are all important but should be looked at separately initially.
The first set of numbers will show the total amount of money that has been paid out of pocket for the month for the medications received. It's important for members to see what they have paid out of pocket for the month for their medications. As the year progresses, this total may increase, depending on what stage of coverage a member is in. The total amount in the accumulated out of pocket expense will help members determine how much they have paid out of their pockets during the course of the year.
The total drug cost for the month column will help the members understand their medications' true cost for the month. This is NOT what they have to pay for the medications. One of the most important things that a member should review is the total drug cost for the year. This is the section that will help patients realize what stage of coverage they are in. When this line has an amount over $2930, they are no longer in the initial coverage period. If the total drug cost accumulated line reads $2930.01 or over, the patients are now in the coverage gap. Once they are in the coverage gap, they should be very careful to monitor this line. Once the total costs of their medications have reached $4700, they are no longer in the coverage gap. When the total cost of their medication reaches $4700.01, they will then be in catastrophic coverage.
These numbers are very important because this will allow members to monitor how close they are to different stages of coverage. When member only takes one medication that is very inexpensive suddenly sees a spike of cost on their EOB, they are able to call their insurance provider to get an explanation and possibly report Medicare fraud.
As members continue to look at their explanation of benefits, they will see that each medication they had filled under their Medicare Part D prescription drug plan has been filled. In this section of the explanation of benefits, the following should be listed: name of the medication, date of service, place of service, the negotiated price of the medication, what the member paid and what the insurance paid for the medication. It is extremely important that patients review this information. It will tell them the exact names of the medications they took, where it was filled and how it will be applied to their prescription plan. If there is something listed they didn't take, it is important that it be reported. All medications that are run through the part D prescription drug plan increases the member's costs and pushes them into different stages of coverage.
This Isn't My Medication. What Do I Do?
If at any time a member notices there are medications they aren't prescribed listed on their explanation of benefits, they should take immediate action. They should call their Medicare Part D prescription drug plan provider. Once they speak with a representative, they should report the specific medications that have been filled and where they were filled that don't belong to them. The representative should be able to contact the pharmacy and investigate further. If it is an act of Medicare fraud, members should file a complaint with their insurance providers as well as with Medicare.
Medicare fraud happens when someone other than the patient uses the patient's benefits to retain medications, supplies and other services they are not entitled to. When a Medicare beneficiary is a victim of fraud, there are many things that can be done, including reversing the medications off their prescription drug insurance. Nothing can be done about Medicare fraud unless it is reported.
With the many things that come in the mail regarding Medicare Part D and the insurance provider, it is extremely important that all mailings be read. When an explanation of benefits comes in the mail, it should be read and questioned if necessary. The only way a Medicare Part D plan will work properly is if there is open communication. An explanation of benefits, EOB, is their way of telling their members what has been done on their behalf. It is up to the members to get an understanding of their explanations by reading the letter.