Shasta-Trinity Schools Insurance Group

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 Total Patient Responsibility for this date of service: $307.50

9. Claims Analysis

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