Helping you understand your benefits

Why understanding your benefits matters

Health insurance words can feel like a foreign language. When you know what your plan pays and what you owe, you can plan ahead, avoid surprises, and feel confident at check-in and at checkout. If you are managing Medicare or a Medicare Advantage plan, a few basics go a long way: what your deductible is, how copays and coinsurance work, and why the Medicare-approved amount or contracted rate matters more than the number on a bill.

This article explains those terms using reliable, noncommercial sources and brings the video guidance to life. You will also see exactly how an advocate can compare your bills with your insurance statements, contact the office on your behalf, and help get incorrect balances adjusted.

If you prefer hands-on support at any point, an advocate can help you analyze bills, coordinate care, and schedule appointments.

Key terms in plain language

Deductible

Your deductible is the amount you pay each year before your plan starts sharing costs for covered services. In Original Medicare Part B, the standard annual deductible is set by the federal government and can change every year. After you meet the deductible, Medicare usually pays 80 percent of the Medicare-approved amount for most Part B services and you pay 20 percent as coinsurance.

Copay

A copay is a set dollar amount you pay for a service. Many Medicare Advantage plans use copays for office visits. For example, your primary care visit might be 0 dollars, 10 dollars, or 20 dollars depending on your plan.

Coinsurance

Coinsurance is a percentage of the allowed or approved amount that you pay after the deductible. With Original Medicare Part B, the common split is 80 and 20. Medicare pays 80 percent of the approved amount and you pay 20 percent. Some services have different cost sharing rules, and preventive care may be fully covered.

Charges you see vs what actually counts

Providers submit a billed charge that can look very high. Your plan uses an allowed amount or contracted rate. You are never responsible for paying 20 percent of the billed charge in Original Medicare when the provider accepts assignment. You pay your share of the Medicare-approved amount instead. For Medicare Advantage, the plan’s contracted rate applies. The difference between the billed charge and the allowed amount is adjusted off for participating providers.

Explanation of Benefits and Medicare Summary Notice

After a claim is processed, you receive an Explanation of Benefits from your health plan or a Medicare Summary Notice for Original Medicare. These are not bills. They show what was billed, what the plan allowed, what the plan paid, and the maximum you may owe the provider. Comparing these notices with any bill you receive is one of the fastest ways to catch errors.

Original Medicare and the 80 and 20 split

Original Medicare is often described as an indemnity style plan. For most Part B services after you meet your deductible, Medicare pays 80 percent of the Medicare-approved amount and you pay 20 percent. The approved amount comes from Medicare fee schedules. If your doctor accepts assignment, they agree to take the approved amount as payment in full. That means you owe only your deductible and coinsurance based on that approved amount. You do not owe the difference between the billed charge and the approved amount for participating providers.

If a provider does not accept assignment, special rules apply and the provider may be able to charge a limited extra amount. This is uncommon with many routine services but is important to ask about before a visit.

Medicare Advantage plans and how cost sharing works

Medicare Advantage plans are offered by private companies approved by Medicare. They bundle Part A and Part B, and many include Part D drug coverage. Instead of the standard 80 and 20 split on the Medicare-approved amount, many services use fixed copays, and some services use coinsurance. Plans can also have deductibles for certain services and an out-of-pocket maximum for in-network care, which Original Medicare does not have on its own.

Because each plan sets its own copays, coinsurance, referral rules, and network, it helps to check your plan details before tests or procedures. You can call the plan, sign in to the plan’s member portal, or let an advocate do this and translate the results into clear next steps.

Putting the video guidance into practice

The video highlighted common pain points and how an advocate can help. Here is how that looks step by step.

Know what really drives your cost

• If you have Original Medicare only, expect to pay your annual Part B deductible first. After that, most covered outpatient services are paid 80 percent by Medicare and 20 percent by you based on the Medicare-approved amount.
• Remember, the 20 percent coinsurance is calculated on the approved amount, not the billed charge. The difference between the billed charge and the approved amount is written off for participating providers. You should not be billed for that difference.

Compare every bill with your insurance statement

• When you receive a bill, match it to your Explanation of Benefits or Medicare Summary Notice. Confirm that the billed services, dates, and codes line up with the EOB or MSN.
• If the balance does not match the EOB or MSN, it may be a billing error, a claim still in process, an out-of-network issue, or a coordination of benefits problem. Do not pay until you understand the difference.

Let Understood Care take the next step

• We compare the bill with your EOB or MSN.
• We call the doctor’s office and the plan, explain why the amount does not match the allowed charge, and request a corrected bill when appropriate.
• We stay on the case until the incorrect balance is adjusted or the explanation makes sense. You always see what we see.

For Medicare Advantage plans

• Many services use a clear copay. For example, primary care could be 0 dollars, 10 dollars, or 20 dollars depending on the plan.
• Some hospital or outpatient services use deductibles and coinsurance. We check your plan’s portal or call your plan, then break the benefits down in plain language so you know what to expect before you schedule.
• We help you confirm network status, prior authorization needs, and whether your visit will count as preventive care or diagnostic care, which can change the cost.

How to check your benefits before a visit

Quick checklist

• Look up your deductible. See how much you have paid so far this year.
• Check your copay or coinsurance for the service. For imaging, outpatient procedures, and durable medical equipment, plans often use coinsurance.
• Confirm network and referrals. Ask if the facility and the clinician are both in network. For Original Medicare, ask whether the doctor accepts assignment.
• Ask about prior authorization. Some tests or medications require plan approval before the visit.
• Request a cost estimate. Ask for the CPT or HCPCS code and the facility location. An estimate based on the contracted rate is more reliable than a number based on the billed charge.

What to bring

• Your insurance card and a photo ID.
• A written list of your medications and allergies.
• Your questions and any prior authorizations.
• If you want help, bring your latest EOB or MSN or share it with your advocate.

Avoiding surprise bills

Several protections limit surprise out-of-network bills for certain situations, such as most emergency care and some services at in-network hospitals. These protections do not cover every scenario. The best prevention is to confirm network status and obtain estimates when possible. If you receive a bill that seems wrong, contact your plan and the provider promptly, and loop in an advocate who can help escalate and resolve disputes.

Real examples of how an advocate helps

• Billed charge vs allowed amount. You receive a bill showing a 500 dollar charge for a test. Your MSN shows a much lower allowed amount. We call the office, reference the allowed amount, and request a corrected bill that reflects your 20 percent coinsurance on the approved amount.
• Copay mismatch in Medicare Advantage. Your plan lists a 0 dollar primary care copay, but you are billed 40 dollars. We share the plan’s benefit page with the office, ask for a rebill with the correct copay, and confirm the updated balance.
• Duplicate billing. Two bills arrive for the same date of service. We match claim numbers on your EOB, confirm only one claim was paid, and have the duplicate charge removed.

When to call your plan or your advocate

• You scheduled a test and are unsure about cost.
• You changed plans and need to confirm new copays or coinsurance.
• You received a bill that does not match your EOB or MSN.
• You are asked to sign a waiver before a procedure and are not sure what it means.
• You want help preparing for open enrollment or comparing options.

You do not have to do this alone. If you want one-to-one help, start with Analyze Bills or Care Coordination.

Frequently asked questions

What is a deductible and when does it reset

A deductible is the amount you pay for covered services each plan year before the plan starts sharing costs. For Original Medicare and most Medicare Advantage plans, the deductible resets on January 1 each year. Plan documents and CMS fact sheets show the specific dollar amounts for the current year.

What is the difference between a copay and coinsurance

A copay is a fixed dollar amount you pay for a service. Coinsurance is a percentage of the approved or contracted rate that you pay after the deductible. Many Medicare Advantage plans use copays for office visits and coinsurance for hospital or outpatient services. Original Medicare Part B commonly uses 20 percent coinsurance after you meet the deductible.

What does Medicare-approved amount mean

This is the amount Medicare sets as payment for a covered service. If your provider accepts assignment, they agree to this approved amount as payment in full. Medicare pays its share and you pay your share based on that amount, not on the provider’s billed charge.

Is an Explanation of Benefits a bill

No. An EOB or a Medicare Summary Notice explains what was billed, what the plan allowed, what the plan paid, and the maximum you may owe the provider. Use it to check any bill you receive for errors.

How can I avoid surprise bills

Confirm that the facility and all clinicians are in network, ask whether prior authorization is required, and request a written estimate with codes before your visit. If you receive a bill that does not match your plan’s allowed amount or your EOB, contact the provider and your plan. An advocate can do this with you or for you.

What is different about Medicare Advantage compared with Original Medicare

Medicare Advantage plans bundle Part A and Part B and often Part D. They set copays and coinsurance, use provider networks, and include an annual out-of-pocket maximum for in-network care. Original Medicare typically uses the 80 and 20 split after the Part B deductible, does not have an out-of-pocket maximum on its own, and does not use networks, though accepting assignment matters for your costs.

Can someone help me check my benefits before a test

Yes. We can call your plan or use the plan portal to confirm your benefits for the specific service and location. We translate the information into plain language so you know what to expect and what questions to ask.

How Understood Care supports you

• We translate your benefits into everyday language so you can make decisions with confidence.
• We compare your bills with your EOB or MSN, then contact the office to correct errors.
• We help you confirm network status, prior authorization, and any copays or coinsurance before you schedule.
• We stay with you until your questions are answered and the balance makes sense.

You can start with Analyze Bills or Care Coordination at any time.

References

• 2025 Medicare Parts A and B Premiums and Deductibles, Centers for Medicare and Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/2025-medicare-parts-b-premiums-and-deductibles Centers for Medicare & Medicaid Services
• Does your provider accept Medicare as full payment, Medicare.gov. https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare Medicare
• Medicare Summary Notice, Medicare.gov. https://www.medicare.gov/basics/forms-publications-mailings/mailings/costs-and-coverage/medicare-summary-notice Medicare
• How to read an Explanation of Benefits, CMS. https://www.cms.gov/medical-bill-rights/help/guides/explanation-of-benefits Centers for Medicare & Medicaid Services
• Understanding Medicare Advantage Plans, Medicare.gov Publication 12026. https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf Medicare
• Your Medicare Benefits, Medicare.gov Publication 10116. https://www.medicare.gov/publications/10116-your-medicare-benefits.pdf Medicare
• Fee Schedules, CMS. https://www.cms.gov/medicare/payment/fee-schedules Centers for Medicare & Medicaid Services
• Coinsurance Glossary, HealthCare.gov. https://www.healthcare.gov/glossary/co-insurance/ HealthCare.gov
• Summary of Benefits and Coverage rights, HealthCare.gov. https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/ HealthCare.gov
• No Surprises Act resources, CMS. https://www.cms.gov/nosurprises Centers for Medicare & Medicaid Services‍

This content is educational and is not a substitute for medical advice. Always consult your healthcare provider for personalized care.