2.11_Combined_A_121015.pdf

Medicare Summary Noticefor Part A (Hospital Insurance) and Part B (Medical Insurance) The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour 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 your $1,068.00  deductible for inpatient hospital  services for the benefit period that began June 18, 2010. Part B Deductible: You have met 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 BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Saba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Facilities and Providers with Claims  This PeriodJuly 29  September 3, 2011  Otero HospitalSeptember 20  October 10, 2011  Heartland Home Health CareOctober 20  November 23, 2011  The New York and Presbyterian HospitalPage 1 of 26Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice December 16, 2011Claims Processed  BetweenOctober 15   December 15, 2011Your Claims & Costs This PeriodDid Medicare Approve All Claims and Services?YESSee page 2 for how to double-check this notice.Total You May Be Billed $119,607.64Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthTHIS IS NOT A BILL | Page 2 of 26 Jennifer WashingtonMaking the Most of Your Medicare  How to Check This NoticeDo 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 FraudIf 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 didnt 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 yearthanks to people who reported suspicious activity to Medicare.  How to Get Help with Your Questions1-800-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 PeriodsYour 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 havent 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 18, 2010.Inpatient Lifetime Reserve:  You have used all of your 60 lifetime reserve days.See your Medicare & You handbook for more information on benefit periods.