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Oscar’s guide to reading EOBs

Whenever you get care, you’ll also get an Explanation of Benefits (EOB). It’ll show you what Oscar will cover vs. what you’ll pay your provider. It may sound simple, but EOBs can be confusing to read. We’re here to help.
Guide to reading EOBs

How EOBs work

After receiving care, your provider will send us your claim. Then:

We’ll send you an EOB (with info about how much you owe the provider)

We’ll send you an EOB (with info about how much you owe the provider)

Your provider will bill you based on your EOB

Your provider will bill you based on your EOB

You’ll pay (You can always check your bills against your EOBs)

You’ll pay (You can always check your bills against your EOBs)

Let’s start at the beginning

This is the “Recent care with Oscar” page. It shows you each date and provider visit, so you can easily find whatever info you need. Think of it as a Table of Contents and use it as your guide.

Just so you know: EOBs will only have this page if they include more than one visit.

Next, you’ll see the cost details of each visit

The “You had a doctor visit with” page might look like a bill, but it’s not. It simply breaks down the cost of your visit and what you’ll owe the provider. (Look out for the bill separately.)

This page includes:

  • The priced charged by your provider (before your insurance kicks in)
  • The savings you’ll get as an Oscar member
  • The amount Oscar has paid based on your co-insurance & deductible
  • The final amount you owe the provider (Tip: this should match the provider bill)
  • A link to more info on the claim (in the bottom left)

How the visit impacts your plan

Look at the bottom right corner of the “Care received'' page. It'll tell you how your visit impacts your plan, including how close you are to reaching your deductible and out-of-pocket max. That way you know when Oscar will start sharing costs with you and when you've paid the most you will pay for care the year.

It also shows how much you owe for coinsurance or your copay, which is the portion you’re responsible for paying out from the full price of a service.

See the FAQs below for more info.

Frequently Asked Questions

    • When you have a health plan and visit a doctor in-network, you'll enjoy the plan discounts we set up for you. (They can be 10-60% below what you would pay if you didn't have insurance.)

      You still may owe something to your provider, depending on how much you’ve used your plan and where you’re at with your deductible (see more about deductibles below).

    • A deductible is the dollar amount you have to pay out-of-pocket for covered services before your health insurance plan begins paying for your care. Here’s how it works:Let's say your plan has a $1,500 deductible. Each month, you'll pay your premium to Oscar to maintain your health coverage. You get some care for free with your Oscar plan, like phone calls with doctors in the Oscar app and preventive care, like an annual physical and flu shot. When you go to the doctor, hospital, therapist, etc. you'll pay for the first $1,500Once your spending reaches your deductible, you'll start paying much less. And if your spending reaches your out-of-pocket-max, you won't spend anything more on covered health care as long as you get care with doctors in our network.Want to know the exact details of your plan? Log in to your account here, or create an account.

    • Your out-of-pocket maximum is the most you'll pay for health expenses in a plan year.

      What does that mean? It means you'll cover the cost of care throughout the year until you meet your plan's deductible. Once you hit your deductible, your health plan will pay for a portion of the cost of services. Then, when you reach your out-of-pocket max, your insurance will cover 100% of the costs for the year.

    • Coinsurance is how much you owe for a covered healthcare service or prescription, calculated as a percentage (e.g. 15%) of the total amount. 

      Here’s an example. Let’s say you make a visit to see a specialist for chronic migraines. Your insurance plan says the total amount for your visit is $100, and your coinsurance is 20%. So you’d pay $20 for your visit, and your insurer would pay the remaining $80.

      If you see a coinsurance on your EOB, it means you reached your deductible. (And that means you’re getting more savings out of your plan.)

    • Copayments (or copays) are fixed dollar amounts (e.g. $20) you’re responsible for paying for a covered appointment, service, durable medical equipment, or prescription. Your copay amount depends on the type of service or item you receive.  You’ll start paying copays when you reach your deductible. And your EOB will help you know whenever this happens.  Log in to see your plan’s Schedule of Benefits to check out your copays for each type of care.

    • When you get an EOB, you won’t pay anything (yet). Your EOB isn’t a bill. So, you’ll want to wait until you receive a bill from your provider. And when you do, you’ll pay them directly. 

      In some cases, you may have already paid the copay or coinsurance when you saw your provider. You also may owe $0, depending on the service.

    • Your EOBs are based on the claims we have on file from your providers. So, you won’t see  adjustments that are in process or a service that hasn’t been filed yet by the doctor or lab. Don’t worry. It’ll come.

    • If the bill you receive from the provider doesn’t look quite right, reach out to them. (They may need to resubmit something to us.) If you still have questions about your EOB, you can message us by logging in here, or creating an account if you need one.