Medicare Summary Notices - English Exhibits - 2.3_Deductible_Benefit_120907.pdf

Page 1 of 5 Medicare Summary Notice for Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services Your Deductible Status Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible: You have now met $798.00 of your $1,068.00 deductible for inpatient hospital services for the benefit period that began May 27, 2011. Be Informed! Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an “On the Go” report to share with your provider. Visit the Web site to sign up and access your personal Medicare information. THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 ¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227) Your Claims & Costs This Period Did Medicare Approve All Claims? NO Number of Services Medicare Denied 2 See claims starting on page 3. Look for NO in the “Claim Approved?” column. See the last page for how to handle a denied claim. Total You May Be Billed $0.00 Facilities with Claims This Period June 18 – June 20, 2011 Otero Hospital June 29 – August 03, 2011 The New York and Presbyterian Hospital Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 Exhibit 2.3a – Part A Deductible and Benefit Days: Inpatient THIS IS NOT A BILL | Page 2 of 5 Jennifer Washington Making the Most of Your Medicare  How to Check This Notice Do you recognize the name of each facility? Check the dates. Did you get the claims listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share. How to Report Fraud If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, Medicare saved tax-payers $4 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare. How to Get Help with Your Questions 1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535. TTY 1-877-486-2048 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555. Your Benefit Periods Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in an SNF for 60 days in a row. Inpatient Hospital: You have 27 out of 90 covered benefit days remaining for the benefit period that began May 27, 2011. See your “Medicare & You” handbook for more information on benefit periods. Your Messages from Medicare Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment. To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicare’s annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined. Exhibit 2.3a – Part A Deductible and Benefit Days: Inpatient Medicare Summary Notice for Part A (Hospital Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services Your Deductible Status Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible: You have now met $0.00 of your $1,068.00 deductible for inpatient hospital services for the benefit period that began June 5, 2010. Be Informed! Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an “On the Go” report to share with your provider. Visit the Web site to sign up and access your personal Medicare information. THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 ¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227) Your Claims & Costs This Period Did Medicare Approve All Claims? NO Number of Services Medicare Denied 2 See claims starting on page 3. Look for NO in the “Claim Approved?” column. See the last page for how to handle a denied claim. Total You May Be Billed $2,062.50 Facilities with Claims This Period June 18 – June 20, 2011 Otero Hospital June 29 – August 03, 2011 The New York and Presbyterian Hospital Page 1 of 5 Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 Exhibit 2.3b – Part A Deductible and Benefit Days: Inpatient & SNF THIS IS NOT A BILL | Page 2 of 5 Jennifer Washington Making the Most of Your Medicare  How to Check This Notice Do you recognize the name of each facility? Check the dates. Did you get the claims listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share. How to Report Fraud If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, Medicare saved tax-payers $4 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare. How to Get Help with Your Questions 1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535. TTY 1-877-486-2048 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555. Your Benefit Periods Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in an SNF for 60 days in a row. Inpatient Hospital: You have 27 out of 90 covered days remaining for the benefit period that began June 5, 2010. Skilled Nursing Facility: You have 63 out of 100 covered days remaining for the benefit period that began June 5, 2010. See your “Medicare & You” handbook for more information on benefit periods. Your Messages from Medicare Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment. To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicare’s annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined. Exhibit 2.3b – Part A Deductible and Benefit Days: Inpatient & SNF Medicare Summary Notice for Part A (Hospital Insurance) and Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid Services Your Deductible Status Your deductible is what you must pay each benefit period for most health services before Medicare begins to pay. Part A Deductible: You have now met $0.00 of your $1,068.00 deductible for inpatient hospital services for the benefit period that began June 5, 2010. Part B Deductible: You have now met your $162.00 deductible for 2009. You have now met your$162.00 deductible for 2010. You have now met $85.00 of your $162.00 deductible for 2011. Be Informed! Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an “On the Go” report to share with your provider. Visit the Web site to sign up and access your personal Medicare information. THIS IS NOT A BILL JENNIFER WASHINGTON TEMPORARY ADDRESS NAME STREET ADDRESS CITY, ST 12345-6789 ¿Sabía que puede recibir este aviso y otro tipo de ayuda de Medicare en español? Llame y hable con un agente en español. 如果需要国语帮助，请致电联邦医疗保险，请先说“agent”, 然后说”Mandarin”. 1-800-MEDICARE (1-800-633-4227) Your Claims & Costs This Period Did Medicare Approve All Claims? NO Number of Services Medicare Denied 2 See claims starting on page 3. Look for NO in the “Claim Approved?” column. See the last page for how to handle a denied claim. Total You May Be Billed $2,062.50 Facilities with Claims This Period June 18 – June 20, 2011 Otero Hospital June 29 – August 03, 2011 The New York and Presbyterian Hospital Page 1 of 5 Notice for Jennifer Washington Medicare Number XXX-XX-1234A Date of This Notice September 16, 2011 Claims Processed Between June 15 – September 15, 2011 Exhibit 2.3c – Part A Deductible and Benefit Days: Part A and B of A combined THIS IS NOT A BILL | Page 2 of 5 Jennifer Washington Making the Most of Your Medicare  How to Check This Notice Do you recognize the name of each facility? Check the dates. Did you get the claims listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share. How to Report Fraud If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, Medicare saved tax-payers $4 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare. How to Get Help with Your Questions 1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535. TTY 1-877-486-2048 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555. Your Benefit Periods Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in a SNF for 60 days in a row. Inpatient Hospital: You have used all of your 90 covered benefit days for the benefit period that began June 5, 2010. Inpatient Lifetime Reserve: You have 37 days out of 60 reserve days remaining. Inpatient Mental Health: You have 185 days out of 190 mental health care days remaining. Skilled Nursing Facility: You have 63 days out of 100 covered days remaining for the benefit period that began June 5, 2010. Your Messages from Medicare Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment. To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicare’s annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined. Exhibit 2.3c – Part A Deductible and Benefit Days: All benefit status days active THIS IS NOT A BILL | Page 2 of 5 Jennifer Washington Making the Most of Your Medicare  How to Check This Notice Do you recognize the name of each facility? Check the dates. Did you get the claims listed? Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount? Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share. How to Report Fraud If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didn’t get. If we determine that your tip led to uncovering fraud, you may qualify for a reward. You can make a difference! Last year, Medicare saved tax-payers $4 billion—the largest sum ever recovered in a single year—thanks to people who reported suspicious activity to Medicare. How to Get Help with Your Questions 1-800-MEDICARE (1-800-633-4227) Ask for “hospital services.” Your customer-service code is 05535. TTY 1-877-486-2048 (for hearing impaired) Contact your State Health Insurance Program (SHIP) for free, local health insurance counseling. Call 1-555-555-5555. Your Benefit Periods Your hospital and skilled nursing facility (SNF) stays are measured in benefit days and benefit periods. Every day that you spend in a hospital or SNF counts toward the benefit days in that benefit period. A benefit period begins the day you first receive inpatient hospital services or, in certain circumstances, SNF services, and ends when you haven’t received any inpatient care in a hospital or inpatient skilled care in an SNF for 60 days in a row. Inpatient Hospital: You have used all of your 90 covered benefit days for the benefit period that began June 5, 2010. Inpatient Lifetime Reserve: You have used all of your 60 lifetime reserve days. Inpatient Mental Health: You have used all of your 190 mental health care days. Skilled Nursing Facility: You have used all of your 100 covered benefit days for the benefit period that began June 5, 2010. Your Messages from Medicare Get a pneumococcal shot. You may only need it once in a lifetime. Contact your health care provider about getting this shot. You pay nothing if your health care provider accepts Medicare assignment. To report a change of address, call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Early detection is your best protection. Schedule your mammogram today, and remember that Medicare helps pay for screening mammograms. Do you use therapy services? Watch the limit! In 2011, Medicare’s annual coverage limit for most outpatient physical therapy and speech language pathology is $1,860 combined. Exhibit 2.3d – Part A Deductible and Benefit Days: All benefit status used