1. Shasta-Trinity Schools Insurance Group
EOB/Benefit Training

2. Agenda Key terms to know
How to read your Explanation of Benefits (EOB)
Real world claims example/comparison
Comparing HMO, PPO, and HDHP plans

3. Key Terms
Participating 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

4. Key Terms
Calendar 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.

5. 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

6. Key Terms
Total 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.

7. 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
$12.00
$0.00
Blood Work
$650.00
$325.00
$238.00
$17.40
$69.60
Total Patient Responsibility for this date of service: $307.50

9. Claims Analysis Summary:
Cardiac incident (chest pains) resulting in visit to urgent care, Ambulance transport,
ER admit for overnight hospital stay.
TOTAL CHARGES
Anthem Discounted Rate
Urgent Care Office Vist and Service
$225.00
$127.59
Ambulance Transport
$2,344.21
$1,447.21
ER Physician Services
$580.00
$396.19
Radiology Services
$274.00
$254.00
ER and Inpatient Hospital Services
$20,819.42
$7,940.00
TOTALS
$24,242.63
$10,164.99
Premier (80/20)
Standard (70/30)
Consumer Choice (70/30)
Uninsured
Urgent Care Copayment
$25.00
N/A
Deductible
$250.00
$1,000.00
$3,750.00
$0.00
Co-Insurance
$1,978.00
$2,742.00
$2,749.50
*Total Member Out of Pocket Expense:
$2,253.00
$3,767.00
$6,499.50
*Assumes Wellness Incentive Credit, Family Deductible
Annual Premium (Tiered/Family)
$16,476.00
$15,912.00
$14,808.00
Total Annual Expenses:
$18,729.00
$19,679.00
$21,307.50

10. 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.

11. Comparing Plan Types HMO PPO High Deductible Health Plan (HDHP) PPO
Referral required for specialists
Yes No
Non-Participating Providers Covered?
Deductible
Deductible applies toward Out-of-Pocket Maximum
Not Applicable
Copayments/Coinsurance applies toward Out-of-Pocket Maximum
Copayments: No
Coinsurance: Yes
Prescription Drug Copayments apply toward Out-of-Pocket Maximum