by admin | Aug 26, 2025 | Custom Content, Employee Benefits, Health Insurance
Ever found a confusing document in your mailbox after a doctor’s visit, wondering if it’s a bill, especially with an “amount you owe” at the bottom? You’re not alone! That document is most likely an Explanation of Benefits (EOB) from your health insurance company. It’s crucial to remember: an EOB is NOT a bill.
Think of your EOB as a detailed receipt or a comprehensive financial statement from your insurance provider. It breaks down the services you received, how much your healthcare provider charged, how much your health plan covered, and any portion you’re responsible for paying. It’s an essential tool for transparency and helps ensure accuracy in your medical billing.
How EOBs Work
The process generally follows these steps:
- Provider Bills Your Insurer: After your medical service, your healthcare provider submits a claim to your insurance company.
- Insurer Processes and Sends EOB: Your insurance company processes the claim, determines coverage based on your plan, and then sends the EOB to you.
- Bill Arrives Separately: You will receive a separate bill from your healthcare provider for the amount you owe after you’ve received and reviewed your EOB. It’s a good practice to wait for your EOB before paying any medical bill to compare the two documents.
What Information Will You Find on an EOB?
While the exact format can vary, most EOBs include similar key sections:
- Account Summary: This lists basic details like the patient’s name, the date(s) of service, and a unique claim number.
- Claim Details: This section provides a breakdown of the specific services you received, including procedure codes, the dates services were provided, and the healthcare provider’s name.
- Amounts Billed & Covered: This crucial part details:
- The total amount your provider charged for each service.
- The amount your health plan paid or approved.
- Any discounts or adjustments negotiated by your insurance company.
- The reason if any portion of the service was not covered (e.g., “not a covered service,” “deductible not met”).
- Your estimated patient responsibility, which is the “amount you owe.”
Remember, insurance rarely covers 100% of costs. Your out-of-pocket expenses will depend on your specific plan’s structure, including:
- Deductible: The amount you must pay for covered healthcare services before your insurance plan begins to pay.
- Copay: A fixed amount you pay for a covered healthcare service, like a doctor’s visit or prescription, usually paid at the time of service.
- Coinsurance: Your share of the costs of a healthcare service, calculated as a percentage (e.g., 20%) of the allowed amount for the service after you’ve met your deductible.
Why Your EOB is So Important
Regularly reviewing your EOB offers several critical benefits:
- Catching Errors: Medical billing errors can occur. Your EOB acts as a window into your medical billing history, allowing you to cross-reference the services listed against what you actually received. You can verify that procedures and diagnoses are coded correctly, potentially saving you money.
- Understanding Your Plan: EOBs provide transparency in the often-complicated world of healthcare finances. By understanding what your plan covers and why certain amounts are or aren’t paid, you gain a clearer picture of how your health insurance truly works.
- Financial Control: Knowing what an EOB is and understanding its contents empowers you to stay in control of your healthcare expenses, ensuring you maximize your benefits and only pay what you genuinely owe.
While an EOB might seem intimidating at first glance, taking the time to understand this document is a vital step in becoming a more informed and empowered healthcare consumer. It’s your financial roadmap to navigating your health plan effectively!
by admin | Aug 18, 2025 | Human Resources
What if employers could capitalize on this current “I quit” mood? If people are leaving jobs for something better, offer something better! Here are some ideas to create an engaged and committed workforce:
1. Understand and Be Responsive to Employee Needs, Motivations, and Priorities
A paycheck may be the reason everyone has a job in the first place, but it’s not the only reason people choose to work or decide to work for one employer over another. Your employees stick with you because there’s something in it for them besides the money. The job is useful to them. Knowing why it’s useful enables you to keep employees satisfied and, better yet, make their jobs even more appealing.
2. Prioritize Employee Development
A work environment in which people gain knowledge, learn new skills, and advance in their careers speaks more clearly and loudly than any marketing message can. People like working where they can grow and develop. According to a LinkedIn report, companies “that excel at internal mobility are able to retain employees nearly twice as long as companies that struggle with it.” And a better trained workforce is also a more productive and profitable workforce!
3. Reward Success
In fact, reward anything you want to see more of. Whether large or small, the rewards have to be meaningful. Ideally, figure out what type of reward speaks to each employee. For some, acknowledgment in a company meeting will make their heart sing. For others, receiving a token of your appreciation, such as a coffee gift card, will be more meaningful.
4. Allow for a Healthy Work-Life Balance
Flexibility is a big selling point for employees looking for better balance between work and life. Your employees have other commitments they need to attend to. Some are caring for young children or other family members while navigating daycare and school closures or multiple appointments. Give employees the time to see to those commitments and have a life outside of work, and you’ll get more from them when they’re on the job. Options may include remote or hybrid work, paid time off, flex hours, four-day workweeks, alternative schedules, and reducing workload. Remember, however, that policies are only as good as the practices around them. Ensure that employees don’t need to jump through hoops to request time off. Remind managers to be responsive to requests for time off and on the look out for signs that employees are feeling overwhelmed.
5. Conduct “Stay Interviews”
Don’t wait until people are leaving to investigate what could have inclined them to stay. Talk to employees now about what’s going well, what pain points they’re experiencing, and what could be done to take the relationship to the next level. Stay interviews enable you to address problems and unfulfilled wishes before they drive people out the door.
By Lisa DeShantz-Cook
Originally posted on Mineral
by admin | Aug 11, 2025 | Health Insurance
Health care terms, medical bills, and forms can be hard to understand. Here are some common health care terms, and what they mean.
Allowed Amount
This is the maximum payment the plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
For example, if you get services during an office visit from an in-network provider and your health plan’s allowed amount for an office visit is $100, you’ll pay $100 for that visit if you haven’t met your deductible, and the visit is subject to the deductible. If you’ve met your deductible, you’ll pay your coinsurance or copayment amount instead, if applicable (see coinsurance, copayment, and deductible).
Under certain circumstances, if your provider is out-of-network and charges more than the health plan’s allowed amount, you may have to pay the difference (see “balance billing”).
Balance Billing
When a provider bills you for the balance remaining on the bill that your plan doesn’t cover. This amount is the difference between the actual billed amount and the allowed amount.
For example, if the provider’s charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider (preferred provider) may not balance bill you for covered services.
Coinsurance
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay the coinsurance plus any deductibles you owe.
For example, if your health insurance plan’s allowed amount for an office visit is $100 and your coinsurance is 20%:
- If you’ve paid your deductible: you pay 20% of $100, or $20. The insurance company pays the rest.
- If you haven’t paid your deductible yet: you pay the full allowed amount, $100 (or the remaining balance until you have paid your yearly deductible, whichever is less).
Complaint
Healthcare providers, emergency facilities, and insurance plans must follow rules that protect consumers from surprise (unexpected out-of-network) medical bills. If you believe your provider, emergency facility, or health plan didn’t follow the rules that protect consumers, you can submit a complaint to the No Surprises Help Desk at 1-800-985-3059. You may need to send supporting documentation like medical bills and your Explanation of Benefits.
Copayment
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service (sometimes called “copay”). The amount can vary by the type of covered health care service.
For example, your health plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20:
- If you’ve paid your deductible, you pay $20, usually at the time of the visit.
- If you haven’t paid your deductible, you pay $100, the full allowed amount for that visit (or the remaining balance until you have paid your annual deductible, whichever is less).
Cost Sharing
This is your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and out-of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover usually aren’t considered cost sharing.
Deductible
An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles.
For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible.
Dispute
If you don’t have health insurance or don’t plan to use your insurance to pay for your care, you may be able to use the patient-provider dispute resolution process if you disagree with your medical bill. In this process, you can ask an independent third party to review your case. The third party, called a dispute resolution entity, will review the good faith estimate, your bill, and information from your health care provider or facility to decide if you should pay the amount on your good faith estimate, the billed charge, or a different amount. During the patient-provider dispute resolution process, you may still negotiate your bill with your provider or facility.
Explanation of Benefits (EOB)
This is a summary from your health plan of the total charges for the health care services you received and how much you and your health plan will have to pay. This could be a paper copy that’s mailed to you or an electronic statement. This is not a bill. Learn more about the explanation of benefits.
Good Faith Estimate (GFE)
An estimate from a health care provider or facility for the expected costs of items or services. If you’re uninsured or not using your insurance, the provider or facility generally must give you a GFE before you get a health care service if you ask for one or if you schedule an appointment at least 3 days before you get a health care service. In certain circumstances, a provider that isn’t in your plan’s network must also give you a GFE as part of its notice and consent to charge you more than your plan’s in-network cost sharing amount. Learn more about good faith estimates.
In-network Providers
Providers or facilities that have a contract with your health plan to provide services for plan members at certain costs. Generally, if you get care with an in-network provider or facility, it will cost you less than if you get care with an out-of-network provider or facility.
Insured
Someone with health insurance (this can include people with insurance through their employer or health insurance they bought through the Health Insurance Marketplace®, directly from an insurance company or through an insurance agent or broker, Medicare, Medicaid, or TRICARE).
No Surprises Act
A federal law that provides protections against getting surprise (unexpected) medical bills for out-of-network emergency room services, some out-of-network non-emergency services related to a patient visit to an in-network facility, and out-of-network air ambulance services.
Notice and Consent Form
A form you may get from out-of-network providers or facilities that tell you about your rights and protections against surprise (unexpected out-of-network) medical bills and that gives you the option to waive those rights. If you sign this form, you agree to give up rights that protect you from balance billing and you may be charged more for your medical care. This form is also known as a waiver. This type of notice and consent form is separate from other medical consent forms that a provider or facility may ask you to sign before treating you. Learn more about notice and consent forms.
Out-of-network Provider
A provider who doesn’t have a contract with your plan to provide services.
If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. This may also be called “nonpreferred provider” or “non-participating provider.”
Out-of-pocket Limit
The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance billed charges or health care your plan doesn’t cover. Some plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.
Preferred Provider
A provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan. You’ll pay less if you see a provider in the network. Also called “preferred provider” or “participating provider.”
Provider
An individual or facility that provides health care services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited as required by state law.
Self-pay
When someone who has health insurance chooses to pay their health care costs out of pocket without using health insurance.
Surprise Bill
An unexpected balance bill for certain types of out-of-network costs your insurance didn’t cover.
Uninsured
Someone without health care coverage.
Originally posted on CMS.gov
by admin | Aug 4, 2025 | Custom Content, Employee Benefits
Employers will see several changes to their health and welfare benefits due to comprehensive new tax and spending legislation. This includes notable improvements to Health Savings Accounts (HSAs), Dependent Care Flexible Spending Arrangements (DCFSAs), and employer-provided student loan payments, as well as the introduction of some new fringe benefit choices.
These updates introduce significant changes to employee benefits. These changes are part of a comprehensive legislative package enacted on July 4, 2025 and will require employers and employees to adjust their understanding and utilization of benefit programs. Some of the most notable provisions are:
- Health Savings Accounts (HSAs) can now cover Direct Primary Care (DPC) fees, up to $150/month for individuals and $300/month for families.
- The telehealth exception for high-deductible health plans (HDHPs) is now permanent, ensuring continued access to virtual care. Employees with HDHPs will have first-dollar coverage of most telehealth services, before meeting their HDHP deductible.
- The dependent care FSA limit has increased from $5,000 to $7,500 ($3,750 for married filing separately), a boost for working parents.
- Bronze and catastrophic ACA exchange plans are now HSA-qualified.
- The tax exclusion for employer-sponsored health insurance remains intact, a win for traditional group benefits.
- Permanent exclusion for student loan assistance allows for a tax exclusion of up to $5,250 per year for employer payments of student loans and offers long-term support for employees managing student debt.
- New tax-advantaged accounts for children (a.k.a. “Trump Accounts”) are individual retirement accounts (IRAs) for children under 18 with an annual contribution cap of $5,000. These accounts allow for employers to contribute up to $2,500 per employee. Additionally, children born between January 1, 2025, and December 31, 2028, are eligible to receive a one-time $1,000 government contribution.
These changes are important as they significantly impact the employee benefits landscape. They also enhance access to care, reduce wait times, and provide greater flexibility, cost savings, and options for both employers and employees. By leveraging these updates, organizations can elevate employee well-being while remaining tax-compliant and strategically competitive.
by admin | Jul 28, 2025 | ACA
Big changes are coming to women’s preventive care coverage! Starting with plan years on or after December 31, 2025, group health plans and health insurance issuers must expand their no-cost coverage for women’s preventive care. This expansion includes additional breast cancer imaging or testing needed to complete an initial mammogram, as well as patient navigation services for breast and cervical cancer screenings.
These updates fall under the Affordable Care Act’s (ACA) preventive care mandate, which requires most health plans to cover a range of preventive services without deductibles, copayments, or coinsurance when using in-network providers. The ACA’s guidelines are regularly updated.
The latest HRSA-supported guidelines, updated on December 30, 2024, specifically expand breast cancer screening to include necessary follow-up imaging (such as MRIs or ultrasounds) or pathology evaluations beyond the initial mammogram. Additionally, starting in 2026, patient navigation services for breast and cervical cancer screening and follow-up will be covered. These services offer personalized support, help with healthcare access, referrals to essential services (like language translation or transportation), and patient education.
