Health Care Statement Gaining Cooperation Letter

[Respondent Name]
[Respondent Address]
[Respondent City, State Zip]

[Month, Year]

Dear [Mr./Ms.] [R Last Name]:
RE: Reviewing Your Health Care Statements for the Medicare Current Beneficiary Survey

Thank you for participating in the Medicare Current Beneficiary Survey. During
your next interview, your interviewer will ask about the type of health care you
received and the costs of these services, including costs not covered by Medicare.
To help ensure that the information we collect is as accurate as possible, please continue
to record your health care related events and save your insurance statements, bills, and
receipts for all medical visits and purchases. When you speak with your interviewer, they
will ask you to find information from these documents.
On the back of this letter, you will find an example Medicare Summary Notice (MSN)
and Prescription Drug Plan (PDP) statement. Although you may not receive these exact
types of documents, we have provided these examples to help you find similar
information on your own statements. We ask that you save this letter so you can
reference these examples during your interview.
As you review your health events and speak with your interviewer, you are making a
meaningful difference in lives of Medicare beneficiaries like you across the country.
We sincerely thank you for your time and effort in providing us the information we
need to improve Medicare. If you have any questions, please do not hesitate to
contact NORC toll-free at 1-844-777-2151, or by email at [email protected].
Sincerely,

Marina Vornovitsky
Director, Medicare Current Beneficiary Survey
Centers for Medicare and Medicaid Services

See Reverse for Example Statements
OMB No. 0938-0568 | Expires 2/29/2024

EXAMPLE MEDICARE SUMMARY NOTICE (MSN) STATEMENT

Your Claims Part B (Medical Insurance)
January 13, 2022
Example Medical Center, (312) 555-7777
PO Box 123456, Chicago, IL 60603-2312
Referred by Doe, John

This section with the grey header lists event information
including the event date and provider.

Service
Approved?

Amount
Provider
Charged

MedicareApproved
Amount

Amount
Medicare
Paid

Yes

$85.00

$74.85

$58.68

$14.97 A,B

$85.00

$74.85

$58.68

$14.97 C

Example

Service Provided & Billing Code

Dr. Doe, Jane T., M.D.

Medicare Summary (MSN) type

Established patient office visit or other
outpatient visit, typically 15 minutes (99213)
Total for Claim #12-12345-123-123

Claim number

Maximum
You May
Be Billed

The bottom row of each column lists the following totals:
Amount Provider Charged, Medicare-Approved
Amount, Amount Medicare Paid, and Maximum You
May Be Billed.

EXAMPLE PRESCRIPTION DRUG PLAN (PDP) STATEMENT
Your prescription drugs during the past month
Your prescriptions for covered
PartCovered
D drugs
Month
December, 2021
PANTOPRAZOLE TAB 40MG
12/10/2020, CVS PHARMACY
Rx#000001234567, 30 Days Supply

Plan paid

$3.00

Prescription
name, form,
strength,
$4.70 &
amount

You paid

Other payments
$2.00

Example

SUCRALFATE SUS 1GM/10ML
12/15/2020, CVS PHARMACY
Rx#000008910111, 12 Days Supply

TOTALS for the month of: December
2021:
Your “out-of-pocket costs” amount is
$9.00. (This is the amount you paid this
month ($9.00) plus the amount of “other
payments” made this month that count
toward your “out-of-pocket costs” ($0.00).
See definitions in Section 3.)
Your “total drug costs” amount is $16.70.
(This is the total for this month of all
payments made for your drugs by the plan
($7.70) and you ($9.00) plus “other
payments” ($0.00).)
OMB No. 0938-0568 | Expires 2/29/2024

$7.70
(total for the
month)

Amount the
plan paid
Total cost

$0.00

$7.00

$0.00

$9.00
(total for the month)

$0.00
(total for the month)

Amount you
paid

See
Notes
Below