!!3? @abcd$ea !bf$%$ga

Dream EOBAARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS) is operated by UnitedHealthcare or its affiliates
AARP MedicarePlans P.O. Box 30770 Salt Lake City, UT 84130-0770
This is not a bill.
It is simply a statement of the medical services you received and details on how you and your plan will share costs. It is called an Explanation of Benefits (EOB). The EOB is generated when your provider (or pharmacy, if applicable) submits a claim for services you received.
Do not use this to pay any outstanding bill.
The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.
We provide free services to help you communicate with us, such as letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card.
ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al 1-800-950-9355, TTY: 711.
1-800-950-9355, TTY: 711.
CEEB TOOM: Yog koj hais Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev mauj nyob rau ntawm koj daim yuaj cim qhia tus kheej.
Your September 2021 Explanation of Benefits October 14, 2021
Hello NANCY D HURT,This is not a bill.
If you owe anything, your provider will send you a bill. Inside you'll find a summary of claims for September. It shows what the plan paid and how much you've paid (or will be billed by your provider). It's called your Explanation of Benefits (EOB).What’s inside?
Questions? We’re here to help. Your current cost summary Call if you have questions about claims or benefits, finding providers
near you, suspicious claims or billing, information in this document, or Your out-of-pocket costs issues about your plan.
Call us toll-free at 1-800-950-9355, TTY/RTT 711, 8 a.m. - 8 p.m. local Your medical and hospital claims processed time, 7 days a week. Or visit www.myAARPMedicare.com.
You can also report suspicious or dishonest billing to Medicare at Your prescription drug claims received 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call
1-877-486-2048). Have questions or think there’s been a mistake?
Your plan information
Part D (prescription drugs) member ID: 627923301
Plan: AARP Medicare Advantage SecureHorizons Plan 1 (HMO-POS)
Go paperless.
Visit your plan website to get your EOB online.
MID 6279233 EOB ID 386742135-H4590-012-000 This is not a bill. Material ID Y0066_Combined_EOB_C 1
Your medical and hospital cost summary This chart is a summary of claims processed in September 2021 and total year to date. Your share includes amounts paid
toward your copays, coinsurance, and deductible. Your share may also include costs that don’t count toward your out-of-pocket maximum, such as denied claims or services. If you owe anything, your provider will send you a bill.
Total cost (allowed Providers billed plan Plan paid Your share
amount)
Totals for September $961.50 $28,370.73 $27,495.99 $874.74
Totals for 2021 $161,554.08 $48,259.63 $46,028.02 $2,231.61
See Your medical and hospital claims processed in September 2021 for specific claim details.
Your prescription drug cost summary
This chart is a summary of claims received in September 2021 and total year to date.
Out-of-pocket cost Total drug cost
Totals for September $0.00 $11.03
Totals for 2021 $18.08 $120.81
See Your prescription drug claims received in September 2021 for detailed information about claims received this month.
Your annual medical and hospital out-of-pocket costs Your out-of-pocket costs (copayments, coinsurance and deductible) show the most money you will have to pay for covered services in a plan year (based on date of service). Some items and services will not count toward that maximum (see your Evidence of Coverage (EOC) to learn more). The amounts listed may include claims in-process and claims paid as of the date noted on page 1 of this EOB. The amounts could change depending on when claims are paid and/or adjusted.
2021 In-Network Annual Out-of-Pocket Maximum
Your plan has a $3,900.00 out-of-pocket maximum. You have $2,814.83 $1,085.17 of $3,900.00 paid
left to pay for covered services for this plan year. The plan pays 100% of the costs after you meet your out-of-pocket maximum.
0 1,950 3,900
2020 In-Network Annual Out-of-Pocket Maximum
Your plan has a $3,900.00 out-of-pocket maximum. You have $2,433.56 $1,466.44 of $3,900.00 paid
left to pay for covered services for this plan year. The plan pays 100% of the costs after you meet your out-of-pocket maximum.
0 1,950 3,900
Your medical and hospital claims processed in September 2021
This chart shows your medical and hospital claims processed in September.
Important information about this claim:
This is a correction to a previous claim because additional information was received.•
Provider: TX HEALTH ARLINGTON Total cost Provider
Plan paid Your shareNetwork Provider (allowed billed plan
Claim #: 45006279233010061-00 amount)
Billing code CLAIM
Room & Board-Private (One Bed)-Medical/Surgical/GYN
Billing code 0111
• You pay a $275.00 copayment for services from a Network Provider.
• Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
• The amount listed as your share is your copayment or coinsurance.
September 15–18, 2020 $3,586.44 $0.00 $0.00 $0.00
Pharmacy-General
Continued
Questions? Call toll-free 1-800-950-9355, TTY/RTT 711, 8 a.m. - 8 p.m. local time, 7 days a week.
EOB ID 386742135-H4590-012-000 This is not a bill. MID 6279233
Material ID Y0066_Combined_EOB_C 4
Network Provider (allowed Plan paid Your share billed plan
Claim #: 45006279233010061-00 amount)
Pharmacy-IV Solutions
Billing code 0258
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.•
September 15–18, 2020 $52.00 $0.00 $0.00 $0.00
Medical/Surgical Supplies and Devices-General
Billing code 0270
• The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
September 15–18, 2020 $8,762.00 $0.00 $0.00 $0.00
Medical/Surgical Supplies and Devices-Sterile Supply
Billing code 0272 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.•
September 15–18, 2020 $49,575.00 $0.00 $0.00 $0.00
Medical/Surgical Supplies and Devices-Other Implants
Billing code 0278
Continued
Claim #: 45006279233010061-00 amount)
Laboratory-General
Billing code 0300
September 15–18, 2020 $726.00 $0.00 $0.00 $0.00
Laboratory-Chemistry
Billing code 0301
September 15–18, 2020 $906.75 $0.00 $0.00 $0.00
Laboratory-Hematology
September 15–18, 2020 $472.50 $0.00 $0.00 $0.00
Laboratory-Bacteriology and Microbiology
Billing code 0306
Continued
Claim #: 45006279233010061-00 amount)
Laboratory-Urology
Billing code 0307
September 15–18, 2020 $318.50 $0.00 $0.00 $0.00
Laboratory-Other Laboratory
Billing code 0309
September 15–18, 2020 $2,060.75 $0.00 $0.00 $0.00
Radiology-Diagnostic-General
September 15–18, 2020 $11,575.75 $0.00 $0.00 $0.00
Operating Room Services-General
Billing code 0360
Continued
Claim #: 45006279233010061-00 amount)
Operating Room Services-Minor Surgery
Billing code 0361
September 15–18, 2020 $3,550.25 $0.00 $0.00 $0.00
Anesthesia-General
Billing code 0370
September 15–18, 2020 $1,244.00 $0.00 $0.00 $0.00
Physical Therapy-General
September 15–18, 2020 $225.00 $0.00 $0.00 $0.00
Physical Therapy-Evaluation or Reevaluation
Billing code 0424
Continued
Claim #: 45006279233010061-00 amount)
Occupational Therapy-General
Billing code 0430
September 15–18, 2020 $557.75 $0.00 $0.00 $0.00
Occupational Therapy-Evaluation or Reevaluation
Billing code 0434
September 15–18, 2020 $331.50 $0.00 $0.00 $0.00
Pulmonary Function-General
September 15–18, 2020 $1,015.00 $0.00 $0.00 $0.00
Recovery Room-General
Billing code 0710
Continued
Claim #: 45006279233010061-00 amount)
EKG/ECG (Electrocardiogram)-General
Billing code 0730
$93,349.44Totals $28,078.12 $27,253.12 $825.00
Claim #: 45006279233010043-01 amount)
Room & Board-Private (One Bed)-Medical/Surgical/GYN
Pharmacy-General
Continued
Claim #: 45006279233010043-01 amount)
Pharmacy-IV Solutions
Medical/Surgical Supplies and Devices-General
Medical/Surgical Supplies and Devices-Sterile Supply
Billing code 0272
Medical/Surgical Supplies and Devices-Other Implants
Billing code 0278
Laboratory-General
Continued
Claim #: 45006279233010043-01 amount)
Laboratory-Chemistry
Laboratory-Hematology
Laboratory-Bacteriology and Microbiology
Billing code 0306
Laboratory-Urology
Laboratory-Other Laboratory
Continued
Claim #: 45006279233010043-01 amount)
Radiology-Diagnostic-General
Operating Room Services-General
Billing code 0360
Operating Room Services-Minor Surgery
Anesthesia-General
Physical Therapy-General
Continued
Claim #: 45006279233010043-01 amount)
Physical Therapy-Evaluation or Reevaluation
Occupational Therapy-General
Occupational Therapy-Evaluation or Reevaluation
Pulmonary Function-General
Recovery Room-General
Continued
Claim #: 45006279233010043-01 amount)
EKG/ECG (Electrocardiogram)-General
Claim #: 2021092700217000001572-00 amount)
February 5, 2021 $170.00 $124.21 $124.21 $0.00
Eye and medical examination for diagnosis and treatment, established patient, 1 or more visits
Billing code 92014
February 5, 2021 $55.00 $18.03 $18.03 $0.00
Assessment for prescription eye wear using a range of lens powers
Billing code 92015 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.•
$225.00Totals $142.24 $142.24 $0.00
Provider: WADE AUMILLER Total cost Provider
Claim #: 2021092800201000001500-00 amount)
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214
You pay a $35.00 copayment for services from a Network Provider.•
Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.•
The amount listed as your share is your copayment or coinsurance.•
Interest paid: -$0.12
Claim #: 2021091300236000002618-00 amount)
Insertion of needle into vein for collection of blood sample
Billing code 36415
$10.00Totals $0.00 $0.00 $0.00
Provider: ROBERT K SMITHERMAN Total cost Provider
Claim #: 2021091300238000001851-00 amount)
Billing code 80053
$29.00Totals $5.91 $5.91 $0.00
Claim #: 2021091400210000003563-00 amount)
PRESENCE/ABSENCE URINARY INCONTINENCE ASSESSED
PAIN SEVERITY QUANTIFIED PAIN PRESENT
Billing code 1125F
Continued
Claim #: 2021091400210000003563-00 amount)
MEDICATION LIST DOCUMENTED IN MEDICAL RECORD
Billing code 1159F
RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD
Billing code 1160F
FUNCTIONAL STATUS ASSESSED
Billing code 1170F
PATIENT SCREENED DEPRESSION
Billing code 1220F
FALLS RISK ASSESSMENT DOCUMENTED
Continued
Claim #: 2021091400210000003563-00 amount)
DOCUMENT COUNSELING EXERCISE CALCIUM & VITAMIN
Billing code 4019F
September 2, 2021 $51.00 $14.74 $0.00 $14.74
Routine EKG using at least 12 leads including interpretation and report
Billing code 93000
You pay a $14.74 copayment for services from a Network Provider.•
Charges are covered under a capitation agreement/managed care plan.•
The amount listed as your share is your copayment or coinsurance.•
September 2, 2021 $219.00 $0.00 $0.00 $0.00
Established patient outpatient visit, total time 30-39 minutes
Billing code 99214-25
Continued
Claim #: 2021091400210000003563-00 amount)
Billing code G0439
This is one of the preventive services that is covered at no cost under Original Medicare, and the plan covers this service at no cost•
to you. Charges are covered under a capitation agreement/managed care plan.•
$510.00Totals $14.74 $0.00 $14.74
Your prescription drug claims received in September 2021
This chart shows your claims for covered drugs received in September. Total drug cost is the cost of each drug (including what you or the plan paid). Price change shows the increase or decrease in the drug price since it was first filled during the plan year. Plan paid includes payments from your Part D plan.
There may be drugs with a lower cost-share or price listed below your current drug. Talk with your prescriber to see if an alternative is right for you.
Pharmacy: OPTUMRX PHARMACY 704 Total drug Price Other Plan paid Your share
Rx #: 000317041902 cost change payments
September 23, 2021 $11.03 0% $11.03 $0.00 $0.00
Hydrochlorot Tab 12.5mg
$11.03 N/ATotals $11.03 $0.00 $0.00
Notes related to September totals:
• Your "out-of-pocket costs" amount is $0.00. This is the amount you paid this month ($0.00) plus the amount of "Other
payments" made this month that count toward your "out-of-pocket" costs ($0.00). See definitions in the Your out-of-pocket costs
and total drug costs section.
Your "total drug costs" amount is $11.03. This is the total for this month of all payments made for your drugs by the plan•
($11.03) and you ($0.00) plus "Other payments" ($0.00). Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs. See definitions in Your out-of-pocket costs•
and total drug costs section.
Continued
Notes related to September totals (continued):
Of the amount for Your share, $0.00 counts toward your out-of-pocket costs.•
Year-to-date totals Total Other Plan paid Your share
January 1, 2021 through September 30, 2021 drug cost payments
$120.81 $102.73 $0.00 $18.08
Your year-to-date amount for “total drug costs” is $120.81.
For more about “out-of-pocket costs" and “total drug costs,” see Your out-of-pocket costs and total drug costs section.
Notes related to year-to-date totals:
Of the amount for Other payments, $0.00 counts toward your out-of-pocket costs.•
Of the amount for Your share, $18.08 counts toward your out-of-pocket costs.•
Your drug payment stage Your Part D prescription drug coverage has drug payment stages. The amount you pay for covered prescriptions depends on which payment stage you are in when you fill it. Whether you move from one payment stage to the next depends on how much is spent for your drugs during the plan year.
$0 You are in this stage $4,130 $6,550
Stage 1: Yearly Deductible Stage 2: Initial Coverage Stage 3: Coverage Gap Stage 4: Catastrophic Coverage
• (Because there is no deductible • You begin in this payment stage • During this payment stage, you • During this payment stage, the for the plan, this payment stage when you fill your first (or others on your behalf) receive plan pays most of the cost for does not apply to you.) prescription of the year. During a 70% manufacturer’s discount your covered drugs.
this payment stage, the plan on covered brand name drugs • You generally stay in this stage pays its share of the cost of your and the plan will cover another for the rest of the calendar year drugs and you (or others on your 5%, so you will pay 25% of the (through December 31, 2021). behalf) pay your share of the negotiated price on brand-name cost. drugs. In addition, you pay 25%
of the costs of generic drugs.• You generally stay in this stage until the amount of your • You generally stay in this stage year-to-date "total drug costs" until the amount of your
reaches $4,130. As of year-to-date "out-of-pocket
09/30/2021, your year-to-date costs" (see Your out-of-pocket
"total drug costs" were $120.81. costs and total drug costs
(See definitions in Section 3.) section) reaches $6,550. When this happens, you move to payment Stage 4, Catastrophic Coverage.
What happens next?
Once you have an additional $4,009.19 in "total drug costs," you move to the next payment stage (Stage 3, Coverage Gap).
Your out-of-pocket costs and total drug costs This section can help you keep track of your out-of-pocket costs and total drug costs to determine which drug payment stage you are in. The drug payment stage you are in determines how much you pay for your prescriptions.
Your out-of-pocket costs Your total drug costs
$0.00 month of September 2021 $11.03 month of September 2021 $18.08 year-to-date (since January 2021) $120.81 year-to-date (since January 2021)
Out-of-pocket costs includes: Total drug cost is the total of all payments made for your covered
• What you pay when you fill or refill a prescription for a covered Part Part D drugs. It includes:
D drug. (This includes payments for your drugs, if any, that are made • What the plan pays by family or friends.) • What you pay
• Payments made for your drugs by any of the following programs or • What others (programs or organizations) pay for your drugs organizations: Extra Help from Medicare; Medicare’s Coverage Gap
Learn more Discount Program; Indian Health Service; AIDS drug assistance
Medicare has made the rules about which types of payments count programs; most charities; and most State Pharmaceutical
and do not count toward out-of-pocket costs and total drug Assistance Programs (SPAPs).
costs. The explanations on this page give you only the main rules. It does not include:
For details, including more about covered Part D drugs, see the • Payments made for: a) plan premiums, b) drugs not covered by our
Evidence of Coverage (EOC), our benefits booklet (for more about plan, c) non-Part D drugs (such as drugs you receive during a
the EOC, see Section 6). hospital stay), d) drugs obtained at a non-network pharmacy that does not meet our out-of-network pharmacy access policy.
• Payments made for your drugs by any of the following programs or organizations: employer or union health plans; some government-funded programs, including TRICARE and the Veteran’s Administration; Worker’s Compensation; and some other programs.
Important things to know about your drug coverage and rights
Your Evidence of Coverage (EOC) has the details about your drug coverage and costs.
• The EOC is our plan's benefits booklet. It explains your drug coverage and the rules you need to follow when you are using your drug coverage.
• You can view the Evidence of Coverage online or call us (our phone number and website are on the cover of this summary) to have a hard copy sent to you.
What if you have problems related to coverage or payments for your drugs?
• Your Evidence of Coverage has step-by-step instructions that explain what to do if you have problems related to your drug coverage and costs. Here are the chapters to look for: – Chapter 7 – Asking the plan to pay its share of a bill you have received for covered services or drugs. – Chapter 9 – What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Here are things to keep in mind:
• When we decide whether a drug is covered and how much you pay, it's called a "coverage decision." If you disagree with our coverage decision, you can appeal our decision (see Chapter 9 of the EOC).
• Medicare has set the rules for how coverage decisions and appeals are handled. These are legal procedures and the deadlines are important. The process can take place if your doctor tells us that your health requires a quick decision.
Continued
EOB ID 386742135-H4590-012-000 This is not a bill. MID 6279233 Material ID Y0066_Combined_EOB_C 25
Important things to know about your drug coverage and rights
Did you know there are programs to help people pay for their drugs?
• Extra Help from Medicare. You may be able to get Extra Help to pay for your prescription drug premiums and costs. This program is also called the "low-income subsidy" or LIS. People whose yearly income and resources are below certain limits can qualify for this help. To see if you qualify for getting Extra Help, see Section 7 of your Medicare & You 2021 handbook or call 1-800-633-4227 for free, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778. You can also call your State Medicaid Office.
• Help from your State's Pharmaceutical Assistance Program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (SHIP). The name and phone numbers for this organization are in Chapter 2, Section 3 of your EOC.
Have questions or think there’s been a mistake?
Part C (medical and hospital): Part D (prescription drugs):
• If you have questions about a claim or think there • If you have questions, contact us: If something is confusing or doesn’t look right on this report, please callmight be a mistake, start by calling your provider. us. Or, you can write to us at AARP MedicarePlans, P.O.• If you still have questions, you can also contact us. We Box 30770, Salt Lake City, UT 84130-0770.can help with questions about:
• You can call your State Health Insurance Assistance– Claims or benefits Program (SHIP). The name and phone numbers for this– Finding providers near you organization are in Chapter 2, Section 3 of your Evidence– Suspicious claims or billing of Coverage.– Information in this document
• What about possible fraud? Most health care– Any issues about your plan professionals and organizations that provide Medicare• You have the right to make an appeal or complaint, services are honest. Unfortunately, there may be somewhich is a formal way to ask us to change our coverage who are dishonest. If the monthly summary shows drugsdecision. You can also make an appeal if we deny a claim or you’re not taking or anything else that looks suspicious,if we approve a claim but you disagree with how much you please contact us.are paying for the item or services. Contact us for more
information.
Learn more atToll-free 1-800-950-9355, TTY/RTT 711, www.myAARPMedicare.com8 a.m. - 8 p.m. local time, 7 days a week
You can report suspicious or dishonest billing to Member Services at the number above or Medicare at 1-800-633-4227, 24 hours a day, 7 days a week (TTY users should call 1-877-486-2048).

!!3? @abcd$ea !bf$%$ga

Documents