What Is Explanation of Benefits
An Explanation of Benefits (EOB) is a document your health insurance plan sends after you receive medical care. It shows what your healthcare provider billed, how much your insurance paid, and what you owe out of pocket. If you receive Medicaid, SNAP, TANF, WIC, or other government benefits with healthcare components, you'll get EOBs for covered medical services.
Why It Matters
EOBs protect you from billing errors and help you understand your actual healthcare costs. Many people receiving government assistance are on tight budgets, so catching mistakes on an EOB can prevent unexpected debt. An error on your EOB might mean you're charged for a service your Medicaid plan should have covered at no cost, or you might be billed twice for the same visit. These errors happen regularly enough that state Medicaid agencies recommend reviewing every EOB you receive.
If you're applying for benefits or trying to maintain eligibility, EOBs also serve as proof of medical expenses. Some benefit programs, like TANF or certain Medicaid waiver programs, track medical spending as part of asset or resource limits. Understanding your EOB helps you track what's actually being paid by insurance versus what's coming from your own pocket.
What Appears on an EOB
- Provider name and address: The doctor, hospital, or clinic that provided the service
- Billed amount: What the provider charged, which may differ significantly from what insurance negotiated rates allow
- Allowed amount: The amount your insurance plan agreed to pay based on negotiated rates (often much lower than the billed amount)
- Insurance payment: The specific dollar amount your plan paid toward the service
- Your responsibility: Any copay, coinsurance, or deductible amount you owe, plus any non-covered services
- Service date and procedure code: When care occurred and what type of care it was (this helps verify the correct service is listed)
How to Review Your EOB
- Check the service dates against your medical records. A date mismatch might indicate billing for a visit you didn't have
- Verify the provider name. Some healthcare systems bill under multiple names, which can be confusing but is usually legitimate
- Look for duplicate claims. If you see the same service listed twice with different EOBs, contact your insurance immediately
- Confirm you actually owe what the EOB says you owe. If you qualified for Medicaid with $0 copays, any balance due is likely an error
- Keep EOBs for at least three years in case you need to dispute a bill or prove you paid for a service
EOBs and Government Benefits Programs
If you receive Medicaid, you'll get EOBs for all covered services. Emergency room visits, doctor appointments, prescription medications, and preventive care should all appear on your EOBs. Medicaid covers these services at no cost to you, so if you see a balance due, it's almost certainly an error unless the service was non-covered (like cosmetic procedures).
SNAP and TANF do not generate EOBs because they're food assistance and cash assistance programs, not healthcare programs. However, some states provide Medicaid to SNAP and TANF recipients automatically, so if you receive those benefits, you likely also have Medicaid coverage with EOBs.
WIC (Women, Infants, and Children) covers specific foods and nutrition services but not medical care, so WIC doesn't generate healthcare EOBs.
Common Questions
What should I do if my EOB shows a balance I don't think I owe? Contact your Medicaid plan's customer service number (on your health insurance card) and dispute the charge. Ask why you're being billed and request a detailed explanation. If it's truly an error, the plan should issue you a corrected EOB and tell the provider to remove the balance from your account. Document the date you called and the representative's name.
Can I get an EOB for a service that happened months ago? Yes. Billing can take 30 to 90 days to process, so EOBs often arrive long after your appointment. If you still haven't received an EOB for a service that occurred more than 120 days ago, contact your plan to request it.
Do I need to keep my EOBs if I'm reapplying for Medicaid or other benefits? Yes. EOBs are proof of what you actually paid for medical care. When you reapply for benefits, case workers sometimes verify your reported medical expenses, and an EOB can back up your claim. They're also useful if you're disputing an eligibility determination.
Related Concepts
- Copay - The fixed dollar amount you pay for a covered service
- Coinsurance - Your percentage share of costs after you meet your deductible
- Deductible - The amount you must pay out of pocket before insurance starts paying