Your explanation of benefits

This guide will help you better understand the key points on your explanation of benefits.

An explanation of benefits (EOB) is a statement you get from your health insurance company after receiving care. It is not a bill. Your EOB breaks down the cost of services you received, showing how much you saved, what your health plan paid, and how much you may owe. If you do owe anything, you will get a bill from your doctor or health care provider(s). We are required to send you an EOB for each month you access care. This information is also available on Sharp Connect.

Page 1 of your EOB

Annual out-of-pocket maximum

Individual and family out-of-pocket expenses, year to date. Out-of-pocket costs include copayments, deductibles (if applicable) and coinsurance. This is the most you have to pay for covered services in a plan year.

Annual deductible

Summarizes individual and family deductibles, year to date. This is the amount to pay in a plan year for specific covered services before your plan starts paying benefits. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.

Page 2 of your EOB

Patient information

Shows which dependent on your plan received care (if applicable). All information on the EOB refers to this individual.

Your claim payment summary

A view of your claim information, shows the amount saved, amount paid by Sharp Health Plan, and amount you may owe your provider.

Date & service

Date of your health care service, description of the service, and the code your provider billed for the service.

Provider billed

Amount your health care provider charged for your service.

Amount allowed

Amount that Sharp Health Plan will pay for a covered health care service with that provider.

We paid

Amount Sharp Health Plan paid the provider towards each service.

Not covered

Portion of the amount billed not covered or eligible under your plan.

Deductible

Amount you need to pay in a plan year for specific covered services before your plan starts paying benefits. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.

Copay/Coinsurance

Copay is a fixed amount you pay for covered health care services after paying your deductible. Coinsurance is a percentage of costs you pay for covered health care services. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.