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Medicare road map: What’s an EOC, why it’s important and how to read one

Color portrait of Mark Pabst By Mark Pabst

One of the first things you learn when shopping for a Medicare plan is that you have a range of options, especially if you choose a Medicare Advantage plan. This means that plans vary in cost and coverage. But no matter which plan you choose, you’ll be able to read a document that provides important details about your plan. It’s generally known as the Evidence of Coverage (EOC).

The EOC is the legal contract between you and the Medicare plan. It’s generally available starting in September and describes costs and benefits of your plan that will take effect on January 1 of the following year. If you have questions about your Medicare plan, start here. While some insurance companies still send a copy of your EOC in the mail, many simply send a notice telling you where you can find it online.

Having your Evidence of Coverage online can be convenient for several reasons. First, you can look at it anytime without having to worry about where you filed away your hard copy. Second, you can use the search function on your computer to scan your EOC for key terms.

This is important because EOCs can be over 200 pages long. (Few people sit down and read them cover to cover.) Your EOC will be more useful and less intimidating if you think of it as a kind of Medicare encyclopedia that you refer to as needed. Below are some sections included in every EOC, along with quick tips on how to find the important information in each section.

It’s a good idea to skim your EOC highlights every year. The graphic below can help you review important sections. If you still have questions, don’t hesitate to contact your plan’s customer service department.

Highlights of EOC
Highlights of EOC

Have questions about your Medicare plan? All Medicare members can read a document online that outlines the plan features. This is usually called your Evidence of Coverage (EOC). Start with the sections shown below to learn about your plan's costs and coverage.

Tip: Printed EOCs can run as long as 200 pages. You can read your EOC online and quickly skim through the sections. You can also use the find function on your computer to search the terms you're interested in.

Information about costs

All EOCs have a section where you can find important details about your costs, including premiums, copays and coinsurance.

Look for this heading if you have questions about:

  • How much you’ll be charged each month for coverage
  • What you’ll pay when you visit the doctor
  • What percentage of a bill you’ll be responsible for paying for covered health care services

Information about coverage

Every EOC has a section on plan benefits. It’s usually in the same chapter as the cost information shown above.

If you're wondering whether your plan helps pay for certain services, such as dental care or depression screening, come directly here.

You'll also find more information about costs. If your plan covers out-of-network care, this is where you will see the price difference between services by a network provider versus an out-of-network provider.

Information about medical emergencies

It helps to know how your plan covers emergency services before you actually need them.

This section defines what is considered an emergency. It can help you decide whether to go to the emergency room, urgent care or walk-in clinic.

In this section, you can learn whether your plan covers follow-up care and when your plan considers an emergency episode over.

What other materials will you get?

You’ll get your EOC, which is a great resource for understanding your plan’s benefits and coverage. You’ll also get your member ID card and a notice that tells you how to get other important documents online or by mail.

If you have a Medicare Advantage plan, this section will tell you where you can find a list of doctors who are in your plan’s network. You’ll also find a list of pharmacies that work with your plan.

If you have a plan that includes prescription drug benefits, this section will direct you to where you can find your plan’s formulary. The formulary lists the drugs that your plan covers.

Your plan may provide other materials, like a membership card or a prescription drug benefit card. This section will tell you what to expect.

Highlights of EOC
Highlights of EOC

About the author

Mark Pabst has worked as a writer and researcher in the health care field for almost two decades. When not writing about health he tries to stay healthy through activities like hiking, climbing and paddling in the far flung corners of his native state of California. However, despite his best efforts he still has a few unhealthy habits he can’t shake, most notably a weakness for jelly donuts.

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