<Plan name> Explanation of Benefits A summary of your health care [plans may add the following phrase, if preferred: , long-term services and supports,] and drug claims for [insert month and year or date range] [Insert mailing date] For <member name> [Plans may also insert a member’s mailing address, member ID number, and/or other information typically used in member communications. Do not use complete HICN.] This is not a bill. [Insert plan’s legal or marketing name] is a health plan that contracts with both Medicare and [insert name of <State> Medicaid program] to provide benefits of both programs to enrollees. This Explanation of Benefits (EOB) is a summary of claims (bills) sent to <plan name> for services and drugs you got during [insert month and year or date range]. The EOB tells you what we paid providers, such as doctors and pharmacies. [Plans with no cost sharing for all services and drugs, delete the rest of this paragraph.] The EOB also shows how much you paid (or can expect to be billed). If you owe anything, your doctors and other health care providers will send you a bill. Disclaimers [Plans that charge $0 copays for all Part D drugs may delete this paragraph.] Copays for prescription drugs may vary based on the level of Extra Help you get. Extra Help is a Medicare program that helps you pay prescription drug costs. Please contact the plan for more details. Limitations [, copays,] and restrictions may apply. For more information, call <plan name> Member Services or read the <plan name> Member Handbook. The Drug List and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits [and/or copays] may change on January 1 of each year. [Plans that do not renew on January 1, revise date as needed.] Other formats
Your health care [plans may add the following phrase, if preferred: and long-term services and supports] claims for [insert month and year or date range] [Insert information for all claims processed during the reporting period.] [If the EOB is being sent to a member who did not have any health care claims or long-term services and supports claims during the reporting period, (1) insert the following note in the first column: No health care claims or long-term services and supports claims for <insert month and year or date range>; and (2) insert amounts of “$0.00” for the columns labeled “Plan’s share” and “Your share.”] NOTE: To describe the services you got, this report uses billing codes and descriptions that were developed and copyrighted by the American Medical Association (all rights reserved). If you do not understand any of the services listed below, call us at <toll-free number> and we can explain the services. <Provider name> [Insert as applicable: In-network or Out-of-network] provider Claim Number: <Claim number> Date(s) of service The date(s) you got the services Plan’s share The amount <plan name> pays for the services Your share The amount you may need to pay for the services [Show each service or item in a separate row.] [Insert description of the service or item that was provided, using the American Medical Association (AMA)'s HCPCS code descriptors and CPT consumer descriptors, followed by the HCPCS or CPT billing code shown in parentheses. For example: Air and bone conduction assessment of hearing loss and speech recognition (billing code 92557).] When HCPCS or CPT codes are not available, health care information in the EOB may include NOC codes and [Insert date(s) of service, using mm/dd/yy format.] $[Insert plan share amount for this service or item.] $[Insert member liability amount for this service or item.] [Note: If service or item has been denied, use either the maximum potential liability or “$0.00” for the