What Is a Medicare Plan Evidence of Coverage?
Short answer
The Evidence of Coverage is the detailed annual document describing a Medicare Advantage or Part D plan’s benefits, costs, rights and operating rules for a specific plan year.
Coverage And Action
Use the current EOC to examine cost sharing, network requirements, authorization, drug procedures, exclusions, grievances and appeals.
Not Automatic
An EOC from a prior year should not be used to establish current benefits, networks, cost sharing or utilization rules.
Practical Example
A Summary of Benefits may list a service copay, while the EOC explains the conditions, authorization rules and limitations that apply.
Questions to verify
- Is this the current plan-year EOC?
- What conditions apply to the benefit?
- Does another plan document control providers or drugs?