2.3_Deductible_Benefit_120907.pdf

Page 1 of 5Medicare Summary Noticefor Part A (Hospital 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 $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 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)Your Claims & Costs This PeriodDid Medicare Approve All Claims? NONumber of Services Medicare Denied 2See 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 $0.00Facilities with Claims This PeriodJune 18  June 20, 2011  Otero HospitalJune 29  August 03, 2011  The New York and Presbyterian HospitalNotice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 2.3a  Part A Deductible and Benefit Days: InpatientTHIS IS NOT A BILL | Page 2 of 5 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 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 MedicareGet 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, Medicares 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: InpatientMedicare Summary Noticefor Part A (Hospital 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 $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 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)Your Claims & Costs This PeriodDid Medicare Approve All Claims? NONumber of Services Medicare Denied 2See 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 $2,062.50Facilities with Claims This PeriodJune 18  June 20, 2011  Otero HospitalJune 29  August 03, 2011  The New York and Presbyterian HospitalPage 1 of 5Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 2.3b  Part A Deductible and Benefit Days: Inpatient & SNFTHIS IS NOT A BILL | Page 2 of 5 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 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 MedicareGet 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, Medicares 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 & SNFMedicare 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 $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 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)Your Claims & Costs This PeriodDid Medicare Approve All Claims? NONumber of Services Medicare Denied 2See 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 $2,062.50Facilities with Claims This PeriodJune 18  June 20, 2011  Otero HospitalJune 29  August 03, 2011  The New York and Presbyterian HospitalPage 1 of 5Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 2.3c  Part A Deductible and Benefit Days: Part A and B of A combinedTHIS IS NOT A BILL | Page 2 of 5 Jennifer WashingtonMaking the Most of Your Medicare