CMS-10453 PPO quarterly summary

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Model Part C Explanation of Benefits
PPO, Quarterly Summary Version
General Instructions
This is a model Part C Explanation of Benefits (EOB). The text in this document is considered model;
therefore any modifications, beyond those allowed or stated below, or as specified by CMS, will render
this EOB a non-model document. As such, the document would be subject to a 45-day review period.
1. Instructions for organizations that send per claim EOBs:


Organizations may choose to send EOBs to non-dual members on either a per claim basis or a
monthly basis. Plans are not required to send an EOB to dual eligible members.
o Organizations that choose to send per claim EOBs can use their own templates for the per
claim EOB as long as the claim information in the EOB includes the American Medical
Association (AMA)’s HCPCS code descriptors and CPT consumer descriptors, followed
by the HCPCS or CPT billing code shown in parentheses. Organizations that choose to
send per claim EOBs must also send this model quarterly summary document to non-dual
eligible members each quarter, even in quarters when there were no claims processed
during the reporting period.
o Organizations that choose to send monthly EOBs should use the “Monthly EOB” model
developed by CMS. Refer to the “Monthly EOB” template for instructions and model
language.

2. Instructions within the template:


Italicized blue text in square brackets is information for the plans. Do not include in the summary
document.



Non-italicized blue text in square brackets is text that can be inserted or used as replacement text
in the summary document. Use it as applicable.



The first time the plan name is mentioned the plan type designation (i.e., HMO, PPO, etc.) must
be included.



When instructions say “[insert month]”, use a format that spells out the full name of the month,
e.g., “January.”

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3. Permissible document alternations:


Minor grammar or punctuation changes, as well as changes in font type or color, are permissible.



References to a specific plan name in brackets may be replaced with generic language such as
“our plan.”



References to Member Services can be changed to the appropriate name your plan uses.



References to the plan’s Optional Supplemental Benefits can be changed to the appropriate name
your plan uses. If desired, you may add a brief description of these services, e.g., “dental
services.”



References to “year” may be changed to “plan year.”



If your plan uses a reporting period that does not correspond exactly to a calendar month, you
may substitute the date range for your reporting period (e.g., “1/1/12 to 2/3/12” OR “January 1 –
February 3, 2013”) whenever instructions say to “[insert month] [insert year].”

4. Instructions for formatting:


With the exception of charts, which should generally be in landscape formation, either landscape
or portrait may be used.



The document is to be formatted as two-column or three-column text (the main title of a section
may extend beyond the first column) to keep line lengths easy to read. Plans may adjust the width
of the columns in the template.



To help conserve paper, the document can be printed double-sided.



The document must have a header or footer that includes the page number. In addition, if desired,
plans may also include any of the following information in the header or footer: member
identifiers, month and year, title of the document.

5. Instructions for HPMS submission:


All plans should submit a Part C EOB through File & Use Certification using the HPMS code
2083.

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[Insert start month for reporting period]
through [Insert end month for reporting period]
[insert year]

Summary of Your
Out-of-Pocket Spending for
Medical and Hospital Claims
For [insert member name]
[If desired, plans name also insert a member ID number
and/or other member numbers typically used in
member communications.]

This is not a bill:
 This report shows the totals for claims we have
processed. It tells what the plan has paid and how much
you have paid (or can expect to be billed). Use this
document to keep track of how much you have spent
“out-of-pocket” for your [remove terms that are not
applicable to your plan: deductible, copayments, and
coinsurance].

[Insert plan name and/or logo]
[Insert Federal contracting statement]
[Plans may insert their Web site URL]

[Insert plan name] Member Services
If you have questions, call us: [Insert phone number]
We are here [insert days and hours of operation].
TTY / TDD only: [Insert TTY/TDD number]
[Plans may insert other Member Services numbers, e.g., a Spanish
customer service number]
-------------------------[Plans that meet the 5% threshold, insert: This information is available for
free in other languages. Please contact Member Services at the number
above.] Member Services [plans that meet the 5% threshold, insert: also]
has free language interpreter services available for non-English speakers.
[Plans that meet the 5% threshold, insert the disclaimer about the
availability of non-English translations in all applicable languages.]

 If you owe anything, your doctors and other health care
providers will send you a bill.
 This report covers medical and hospital care only. [MAonly plans omit the next sentence.] We send a separate
report on Part D prescription drugs.

[Plans may include the member’s mailing address on this
cover page.]

The benefit information provided is a brief summary, not a complete
description of benefits. For more information, contact the plan. [Omit terms
in the following sentence that are not applicable to the plan:] Benefits,
formulary, pharmacy network, premium, copayments, and coinsurance may
change on January 1 of each year. [Plans that do not renew on January 1,
revise date as needed in previous sentence.]
[Insert material ID] Accepted

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[In the “totals” section, plans must insert the total amounts for all claims for Part A and Part B services and mandatory supplemental benefits.
Amounts for claims for optional supplemental benefits should be excluded from the totals section.]

TOTALS
for medical and hospital claims

Totals for this quarter (for claims
processed from [insert reporting period
start date] to [insert reporting period end
date])

Amount
providers
have billed
the plan
$[insert
total billed
amount for
the
reporting
period]

Total cost
(amount the plan
has approved)

Plan’s share

Your share

$[insert total
approved amount
for the reporting
period]

$[insert total
plan share
amount for
the reporting
period]

$[insert total
member liability
amount for the
reporting
period]

$[insert total
approved
amount for the
year]

$[insert total
plan share
amount for
the year]

$[insert total
member liability
amount for the
year]

[If no claims
were
processed,
insert:
(No claims
were
processed this
quarter.)]

Totals for [insert year] (all claims
processed through insert reporting period
end date])

$[insert
total billed
amount for
the year]
[If no claims
to date,
insert:
(No claims
have been
processed
this year.)]

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[Plans with no deductibles,
omit this section.]

DEDUCTIBLE:
For most covered services,
the plan pays its share of the
cost only after you have paid
your yearly plan deductible.
As of [insert reporting period
end date], you have paid
[insert as applicable: [insert
amount member has paid
toward deductible if less than
the full deductible amount]
toward OR the full amount of]
your [insert deductible
amount] yearly plan
deductible.
[Plans are permitted, but not
required, to include a graphic,
such as the one shown below, to
illustrate the member’s progress
toward the deductible:

$0

$250
= your yearly
plan deductible]

YEARLY LIMITS – these limits give you financial protection
These limits tell the most you will
have to pay in [insert year] in
“out-of-pocket” costs ([Delete
references to deductibles,
copayments, or coinsurance if not
applicable for the plan:] copays,
coinsurance, and your deductible)
for [insert as applicable: medical
and hospital services covered by
the plan OR covered Part A and
Part B services].
These yearly limits are called your
“out-of-pocket maximums.” They
put a limit on how much you have
to pay, but they do not put a limit
on how much care you can get.
This means:
 Once you have reached a
limit in out-of-pocket costs,
you stop paying.
 You keep getting your
covered services as usual,
and the plan will pay the
full cost for the rest of the
year.

In-network limit
In [insert year], $[insert in-network MOOP amount] is the most
you will have to pay for covered services you get from innetwork providers.
As of [insert reporting period end date], you have had [insert
amount paid toward in-network MOOP as of reporting period
end date] in out-of-pocket costs that count toward your [insert
in-network MOOP amount] out-of-pocket maximum for covered
in-network services.
[Plans are permitted, but not required, to include a graphic such
as the one shown below to illustrate the member’s progress
toward the MOOP:

$0

$3,400 ]

Combined (in-network + out-of-network) limit
In [insert year], $[insert combined MOOP amount] is the most
you will have to pay for covered services you get from all
providers (in-network providers + out-of network providers
combined).
As of [insert reporting period end date], you have had [insert
amount paid toward combined MOOP as of reporting period
end date] in out-of-pocket costs that count toward your [insert
combined MOOP amount] combined out-of-pocket maximum
for covered services.
[Plans are permitted, but not required, to include a graphic such
as the one shown below to illustrate the member’s progress
toward the MOOP:

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$0

$3,400 ]