Health Care Statement Gaining Cooperation Letter

Dear [Mr./Ms.] [R Last Name]:
RE: Reviewing Your Health Care Statements for the Medicare Current Beneficiary
Survey (MCBS)
Next time, your interviewer will ask about your recent health-related visits and purchases,
and the costs of each. You may wish to record the dates of your health care visits and
purchases. Please keep your insurance statements, bills, and receipts for all your visits
and purchases. Save this sheet for your next interview; it will help you and your
interviewer record information about your health care.
An example Medicare Summary Notice (MSN) is below. An example Prescription Drug
Plan (PDP) statement is on the reverse.

Your Claims Part B (Medical Insurance)
January 13, 2021

Example Medical Center, (312) 555-7777
PO Box 123456, Chicago, IL 60603-2312
Referred by Doe, John
Service Provided &
Billing Code

Medicare Summary
(MSN) type

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

Amount Medicare Amount Maximum
See
Service Provider Approved Medicare You May Notes
Approved? Charged Amount
Paid Be Billed Below

Dr. Doe, Jane T., M.D.
Established patient office
visit or other outpatient
visit, typically 15 minutes
(99213)
Total for Claim #1212345-123-123

Claim
number
OMB No. 0938-0568
Expires 8/31/2025

Yes

$85.00

$74.85

$58.68

$14.97 A,B

$85.00

$74.85

$58.68

$14.97 C

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
Plan paid

You paid

Your prescriptions for
covered Part D drugs
Month Covered
December, 2020
$3.00
$2.00
PANTOPRAZOLE TAB
40MG
Prescription
12/10/2020, CVS
name, form,
PHARMACY
strength, &
Rx#000001234567, 30 Days
amount
Supply
$4.70
$7.00
SUCRALFATE SUS
1GM/10ML
12/15/2020, CVS
PHARMACY
Rx#000008910111, 12 Days
Supply
TOTALS for the month of:
$7.70
December 2020:
(total for
Your “out-of-pocket costs”
the month)
amount is $9.00. (This is the
amount you paid this month
($9.00) plus the amount of
Amount
“other payments” made this
the plan
month that count toward your
paid
“out-of-pocket costs” ($0.00).
See definitions in Section 3.)
Your “total drug costs”
Total cost
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 8/31/2025

$9.00
(total for the
month)

Amount
you paid

Other payments

$0.00

$0.00

$0.00
(total for the
month)