Explanation of Benefits

Part D plans are required to provide a monthly Explanation of Benefits (EOB) notice to each enrollee that uses his/her plan to obtain prescription drugs. The notice is to be sent at the beginning of the month following the month in which prescription drugs are obtained. The EOB notice may also include information about any formulary changes.

CMS Resources

CMS Releases Update on the New EOB Notice NEW!
April 2008 -- CMS issued a clarification around the implementation of new Explanation of Benefits (EOB) notices for plan sponsors to use when conveying information to enrollees regarding any benefit or formulary changes. CMS expects plan to begin using the model notice in July so that Medicare beneficiaries begin to receive EOB new notices in August 2008 (for the month of July). One helpful change to the notice for SHIP counselors and beneficiaries is additional information regarding whether or not secondary payer or other sources count towards TrOOP. CMS has also released a summary chart for plans to use when conveying information to enrollees about their Medicare drug costs.

CMS Update on the 2008 Model Explanation of Benefits
February 2008 -- Part D enrollees will receive new Explanation of Benefits (EOBs) from their plans in August 2008, in accordance with CMS deadlines [http://www.hapnetwork.org/assets/pdfs/cms-memo-eob.pdf]. However, some plans may start using the new EOBs earlier.

A February update from CMS states that the model EOB, issued in September 2007, has been revised to better reflect the level of detail that is needed regarding TrOOP balance transfers. The revision removes the names of the previous plans from which True Out-Of-Pocket (TrOOP) balance transfers had been received by a beneficiary's current plan.

CMS provided the plans with a model cover letter and EOB framework, although the plans do not necessarily have to use this format.

HAP Resources

FAQs: Beneficiary Notices

• What do the auto-enrollment notices sent to full dual-eligible Medicare beneficiaries say?
• Is there a mandatory template for the monthly Part D Explanation of Benefits (EOB) notice?
• Should Part D plans include special text for duals and other LIS recipients so they know the doughnut hole does not apply to them?

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