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Claims 101: Your guide to understanding how you pay for care
Learn how to decode your Explanation of Benefits and track your spending with this simple guide.
Oscar 101Oscar Member Resources
3 min read
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*This post is the latest in our “Oscar 101” series, where we help you understand how to make the most of your Oscar plan. Read previous entries here (opens in new tab). *
Seeing a medical claim can be stressful. Your first thought is often, “How much do I owe?”
But a health insurance claim isn’t actually a bill. It’s a crucial piece of communication between your doctor and your insurance plan. Understanding claims is one of the best ways to manage your healthcare costs and ensure you’re getting the most out of your benefits.
Here is our simple guide to decoding the claims process and how we work together to cover your care.
What exactly is a claim?
At its simplest, a claim is a detailed list of the services you received and what each one costs. When you visit a doctor or hospital, they send this list to us at Oscar.
We review the claim against your specific plan details to determine what services are covered, what discount we have negotiated with that provider, and what amount you may still owe them.
Before you receive a final bill from your doctor, you will receive an “Explanation of Benefits” (EOB) from us summarizing this entire process. (It’s important to remember that the EOB itself is not a bill!)
How a claim gets paid and how much you contribute depends on where you are in your coverage journey for the year. The cost-sharing model usually falls into one of three buckets:
The Deductible: The deductible is a set dollar amount you pay for covered health services before your plan begins to pay. If your deductible is $2,000, you will pay 100% of your initial eligible bills (like specialized tests or procedures) until you have paid that $2,000. You must meet this amount every new plan year.
Copay: A copay is a pre-determined, fixed fee you pay at the time of service, usually for routine care. Think of it as your predictable, immediate cost. For example, your plan might specify a $30 copay for a regular office check-up or $15 for a generic prescription. Copays often apply before you meet your deductible, depending on your plan.
Coinsurance: Coinsurance is your share of the cost of a service, calculated as a percentage. This usually kicks in after you have met your deductible for the year. If your plan’s allowed amount for a service is $100 and your coinsurance is 20%, you pay $20, and your plan covers the remaining $80.
Checking your progress
Every time a claim is processed, your contributions automatically count towards your “Out-of-Pocket Maximum,” which is the absolute limit on what you will pay in a year. Once you hit that max, your plan pays 100% of all covered costs.
The best way to stay on top of your budget and your health is to monitor your claims regularly. It’s how you track exactly how much you’ve paid and how close you are to maximizing your benefits.
Ready to see where you stand? Log in to your member account to view your claims here (opens in new tab).
