CMS Pub. 100-04, ch. 21, § 10.3.5

(Page 2)

(Rev. 11509, Issued: 07-28-22, Effective: 01-01-23 Implementation: 01-03-23)

A. Section Title

POSITION

This subsection contains information of a fixed size. It does not vary in overall width or

length.

The content area begins (0˝, 5˝), 7 points from the baseline of the Headers for Other

Pages subsection. It is full-page or 540 points in width and 24 points in height.

FORMATTING

[GR 2.1] black rule

[TH 2] section name

DYNAMIC RULES

N/A - this section is static.

CONTENT

Making the Most of Your Medicare

B. How to Check This Notice

Global Specifications

POSITION

This subsection contains information of varying size per MSN type. It does not vary in

overall width or length per type.

The content area begins (0˝, 0.94˝), 28 points from the baseline of the Section Title

subsection. It is one-column or 259 points in width and varies in height depending on the

MSN type. Content is static per type.

Indent 8 points from the top, left, and right, and 12 points at bottom to begin content area.

FORMATTING

[GL 9] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.2] first sentence of each paragraph [TB 1.1] remaining text in each paragraph

[GR 6] space between paragraph

[TB 1.2] first sentence of each paragraph [TB 1.1] remaining text in each paragraph

[GR 6] space between paragraph

[TB 1.2] first sentence of each paragraph [TB 1.1] remaining text in each paragraph

DYNAMIC RULES

The body-text content varies depending on which member of the extended family the

MSN belongs to - see the content specifications below.

PART A INPATIENT AND ‘B OF A’, SPECIFICATIONS

CONTENT

How to Check This Notice

Do you recognize the name of each facility? Check the dates.

Did you get the claims listed? Do they match those listed on your receipts and bills?

If you already paid the bill, did you pay the right amount? Check the maximum you

may be billed. See if the claim was sent to your Medicare supplement insurance

(Medigap) plan or other insurer. That plan may pay your share.

HOSPICE AND HOME HEALTH SPECIFICATIONS

CONTENT

How to Check This Notice

Do you recognize the name of each doctor or provider? Check the dates. Did you

have a visit or service that day?

Did you get the services listed? Do they match those listed on your receipts and bills?

If you already paid the bill, did you pay the right amount? Check the maximum you

may be billed. See if the claim was sent to your Medicare supplement insurance

(Medigap) plan or other insurer. That plan may pay your share.

PART B (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

How to Check This Notice

Do you recognize the name of each doctor or provider? Check the dates. Did you

have an appointment that day?

Did you get the services listed? Do they match those listed on your receipts and bills?

If you already paid the bill, did you pay the right amount? Check the maximum you

may be billed. See if the claim was sent to your Medicare supplement insurance

(Medigap) plan or other insurer. That plan may pay your share.

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

How to Check this Notice

Do you recognize the name of each supplier? Check the dates. Did you make a

purchase that day?

Did you get the items/services listed? Do they match those listed on your receipts and

bills?

If you already paid the bill, did you pay the right amount? Check the maximum you

may be billed. See if the claim was sent to your Medicare supplement insurance

(Medigap) plan or other insurer. That plan may pay your share.

C. How to Report Fraud

Global Specifications

POSITION

This subsection is fixed in width and varies in length depending on content, however the

position is dynamic.

The content area begins 19 points from the baseline of the How to Check This Notice

subsection. It is one-column or 259 points in width.

FORMATTING

[GR 2.1] black rule

[GL 10] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.1] body text

[GR 6] space between paragraph

[TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] first sentence highlight [TB 1.1] body text

DYNAMIC RULES

Body-text content in the first paragraph varies depending on which member of the

extended family the MSN belongs to - see the content specifications below.

The third and final paragraph of this section contains a fraud-specific message from

CMS. The message must be a maximum 185 characters long (inclusive of spaces). The

current fraud-specific message can be found on the CMS website:

http://www.cms.gov/Medicare/Medicare-General-Information/MSN/index.html?redirect=/MSN/02_MSNMessages.asp

PART A INPATIENT AND ‘B OF A’, SPECIFICATIONS

CONTENT

How to Report Fraud

If you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-

800-633- 4227).

Some examples of fraud include offers for free medical services or billing you for

Medicare services you didn’t get. If we determine that your tip led to uncovering fraud,

you may qualify for a reward.

{CMS fraud message of 185 characters (four lines of text) The first sentence may be

bold, while the remaining text is roman, with occasional bits, such as monetary figures

or important words, highlighted in bold.}

PART B (ASSIGNED AND UNASSIGNED), HOSPICE, AND HOME HEALTH

SPECIFICATIONS

CONTENT

How to Report Fraud

If you think a provider or business is involved in fraud, call us at 1-800-MEDICARE (1-

800-633- 4227).

Some examples of fraud include offers for free medical services or billing you for

Medicare services you didn’t get. If we determine that your tip led to uncovering fraud,

you may qualify for a reward.

{CMS fraud message of 185 characters (four lines of text) The first sentence may be

bold, while the remaining text is roman, with occasional bits, such as monetary figures

or important words, highlighted in bold.}

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

How to Report Fraud

If you think a supplier or business is involved in fraud, call us at 1-800-MEDICARE (1-

800-633- 4227).

Some examples of fraud include offers for free medical services or billing you for

Medicare services you didn’t get. If we determine that your tip led to uncovering fraud,

you may qualify for a reward.

{CMS fraud message of 185 characters (four lines of text) The first sentence may be

bold, while the remaining text is roman, with occasional bits, such as monetary figures

or important words, highlighted in bold.}

D. How to Get Help with Your Questions

GLOBAL SPECIFICATIONS

POSITION

This subsection contains information of a fixed size. It does not vary in overall width or

length.

This subsection begins 19 points below the How to Report Fraud subsection. It is one-column or 259 points in width and 142 points in height.

FORMATTING

[GR 2.1] black rule

[GL 11] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.2] phone number

[TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] TTY phone number [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.1] body text [TB 1.2] SHIP phone number highlight

DYNAMIC RULES

This subsection contains three pieces of dynamic content: language in the first paragraph

that’s variable by extended-family member; a MAC ID number; and the SHIP phone

number.

Body-text content in the first paragraph varies depending on which member of the

extended family the MSN belongs to - see the content specifications below.

The first paragraph also contains the printing MAC’s ID number, in order to assist in

tracking and routing beneficiary calls to the Medicare call center. This ID number is

referred to on the notice as a “customer-service code.”

The final paragraph should contain the primary phone number for the State Health

Insurance Office, corresponding to the state listed in the notice mailing address in Section

1. The phone numbers for the SHIP offices can be found on the CMS website:

http://www.medicare.gov/contacts/organization-search-criteria.aspx.

NOTE: If the mailing address is that of the legal representative and the beneficiary’s

address indicates that the beneficiary lives outside of the 50 U.S. states and U.S.

territories, then the final paragraph should be suppressed.

PART A INPATIENT, HOSPICE, HOME HEALTH, AND ‘B OF A’, SPECIFICATIONS

CONTENT

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “hospital services” Your customer-service code is {5-DIGIT A/B MAC (A) ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

Contact your State Health Insurance Program (SHIP) for free, local health insurance

counseling. Call {10-DIGIT PHONE NUMBER FOR SHIP IN RECIPIENT’S STATE

OF RESIDENCE}.

Or, if the MSN mailing address is outside the 50 states:

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “hospital services.” Your customer-service code is {5-DIGIT A/B MAC (A) ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

PART B (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “doctors services.” Your customer-service code is {5-DIGIT A/B MAC (B) ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

Contact your State Health Insurance Program (SHIP) for free, local health insurance

counseling. Call {10-DIGIT PHONE NUMBER FOR SHIP IN RECIPIENT’S STATE

OF RESIDENCE}.

Or, if the MSN mailing address is outside the 50 states:

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “doctors services.” Your customer-service code is {5-DIGIT A/B MAC (B) ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

DME (ASSIGNED AND UNASSIGNED) SPECIFICATIONS

CONTENT

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “medical supplies.” Your customer-service code is {5-DIGIT DME MAC ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

Contact your State Health Insurance Program (SHIP) for free, local health insurance

counseling. Call {10-DIGIT PHONE NUMBER FOR SHIP IN RECIPIENT’S STATE

OF RESIDENCE}.

Or, if the beneficiary’s pricing state is outside the 50 U.S. states and U.S. territories:

How to Get Help with Your Questions

1-800-MEDICARE (1-800-633-4227)

Ask for “medical supplies.” Your customer-service code is {5-DIGIT DME MAC ID

CODE}.

TTY 1-877-486-2048 (for hearing impaired)

E. Your Benefit Periods

This subsection is only for Part A Inpatient MSNs. It can also be included in combined

Part A Inpatient and ‘B of A’ MSNs. It should be suppressed for Hospice, Home Health,

Part B (assigned and unassigned), and DME (assigned and unassigned).

The Your Benefit Periods subsection may contain up to three dynamically generated

content units, providing beneficiary-specific information related to inpatient hospital

benefit days, inpatient lifetime reserve days, inpatient mental health care in a psychiatric

hospital limit, and skilled nursing facility (SNF) benefit days.

Language variations exist to describe whether a beneficiary has used all their benefit days

for a given type of claim period, or if benefit days remain.

See Exhibit 2.3 for examples of different scenarios regarding benefit periods.

POSITION

This subsection begins (3.9˝, 0.94˝). This should top align with the How to Check This

Notice subsection on the left column. It is one-column or 259 points in width with a

variable height, dependent on dynamic content.

FORMATTING

[GR 2.1] black rule

[GL 12] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.1] body text of intro paragraph [TB 1.2] text in bold

[GR 3.1] dotted rule

[TB 2.2] headers for benefit period types [TB 1.1] beneficiary-specific dynamic data

within benefit-period info

[GR 3.1] dotted rule

[TB 2.2] headers for benefit period types [TB 1.1] beneficiary-specific dynamic data

within benefit-period info

[GR 3.1] dotted rule

[TB 1.2] final paragraph

INPATIENT HOSPITAL DAYS

Content in the beneficiary-specific portion of this subsection is subject to the following

variations:

• If a claim on the notice is for an inpatient hospital stay, and

• The benefit period associated with the claim was still active on the notice date of

the MSN - because fewer than 60 days had passed between the last claimed date

of stay in the benefit period and the notice date - then this subsection should list

how many covered benefit days remain in the benefit period; or

• The benefit period associated with the claim is closed - because more than 60

days had passed since the last claimed date of stay and the notice date - then this

subsection should indicate that the benefit period has ended.

• There is no benefit period associated with the claim because it was rejected,

therefore no benefit days were used.

The possible dynamic statements for inpatient hospital days are as follows:

You have {#} out of 90 covered benefit days remaining for the benefit period that

began {Month DD, YYYY}.

or

You have used all of your 90 covered benefit days for the benefit period that began

{Month DD, YYYY}.

or

The benefit periods for all claims on this notice have ended.

or

You didn’t have an active benefit period.

LIFETIME RESERVE DAYS

Content in the beneficiary-specific portion of this subsection is subject to the following

variations:

• If a claim on the notice is for an inpatient hospital stay and all inpatient hospital

benefit days for the benefit period have been exhausted, and all or a portion of the

claimed days have been paid using inpatient lifetime reserve days, and

• The beneficiary still has some number of inpatient lifetime reserve days available,

then this subsection should list the remaining inpatient lifetime reserve days the

beneficiary had on the date of the notice; or

• The beneficiary had exhausted all of their inpatient lifetime reserve days, then this

subsection should indicate that all inpatient lifetime reserve days have been used.

• The beneficiary did not use any inpatient lifetime reserve days because the claim

was rejected.

The possible dynamic statements for inpatient lifetime reserve benefit days are as

follows:

You have {#} out of 60 lifetime reserve days remaining.

or

You have used all of your 60 lifetime reserve days.

or

You didn’t have an active benefit period.

INPATIENT MENTAL HEALTH DAYS

Content in the beneficiary-specific portion of this subsection is subject to the following

variations:

• If a claim on the notice is for an inpatient mental health care in a psychiatric

hospital stay, and

• The beneficiary still has some number of lifetime mental health care days

available, then this subsection should list the remaining lifetime mental health

care days the beneficiary had on the date of the notice; or

• The beneficiary had exhausted all of their lifetime mental health care days, then

this subsection should indicate that all lifetime mental health care days have been

used.

• The beneficiary did not use any mental health care days because the claim was

rejected.

The possible dynamic statements for inpatient lifetime reserve benefit days are as

follows:

You have {#} out of 190 mental health care days remaining.

or

You have used all of your 190 mental health care reserve days.

or

You didn’t have an active benefit period.

SKILLED NURSING FACILITY DAYS

Content in the beneficiary-specific portion of this subsection is subject to the following

variations:

• If a claim on the notice is for a skilled nursing facility (SNF) stay, and

• The benefit period associated with the claim was still active on the notice date of

the MSN - because fewer than 60 days had passed between the last claimed date

of stay in the benefit period and the notice date - then this subsection should list

how many covered benefit days remain in the benefit period; or

• The benefit period associated with the claim is closed - because more than 60

days had passed since the last claimed date of stay and the notice date - then this

subsection should indicate that the SNF benefit period has ended.

• There is no benefit period associated with the claim because it was rejected,

therefore no benefit days were used.

The possible dynamic statements for skilled nursing facility hospital days are as follows:

You have {#} out of 100 covered benefit days remaining for the benefit period that

began {Month DD, YYYY}.

or

You have used all of your 100 covered benefit days for the benefit period that began

{Month DD, YYYY}.

or

The benefit periods for all claims on this notice have ended.

or

You didn’t have an active benefit period.

DYNAMIC RULES

In an open inpatient hospital or skilled nursing facility benefit period, the number of

remaining covered/reserve days should reflect the number of days that remained on the

notice date. If the beneficiary had no remaining benefit days on that date, but the period

was still open, then the second inpatient/SNF statement above should be used, indicating

that all benefit days have been used for the period beginning on the stated date.

Only one active benefit period related to the claims listed on the statement should be

printed. If there are any additional claims that pertain to another benefit period, suppress

the status.

If claims on the notice use any combination of inpatient hospital days, inpatient lifetime

reserve days, inpatient mental health care days or skilled nursing facility (SNF) days,

then all of the applicable statements, as described above, should be included in this

subsection.

If claims did not use lifetime reserve days or inpatient mental health care days, suppress

this section and list skilled nursing facility benefit period immediately after inpatient

hospital.

CONTENT

Static content, and sample dynamic content, is as follows:

Your Benefit Periods

Your hospital and skilled nursing facility (SNF) stays are measured in benefit days

and benefit periods. Every day that you spend in a hospital or SNF counts toward

the benefit days in that benefit period. A benefit period begins the day you first

receive inpatient hospital services or, in certain circumstances, SNF services, and

ends when you haven’t received any inpatient care in a hospital or inpatient skilled

care in a SNF for 60 days in a row.

Inpatient Hospital: You have {#} out of 90 covered benefit days remaining for the

benefit period that began {Month DD, YYYY}.

Inpatient Lifetime Reserve: You have {#} out of 60 lifetime reserve days

remaining.

Inpatient Mental Health: You have {#} out of 190 mental health care days

remaining.

Skilled Nursing Facility: You have {#} out of 100 covered benefit days remaining

for the benefit period that began {Month DD, YYYY}.

See your “Medicare & You” handbook for more information on benefit periods.

F. Medicare Preventive Services

This subsection is only for Part B assigned and unassigned MSNs. It should be

suppressed on all other types including Part A Inpatient, Hospice, Home Health, ‘B of A’,

and DME. For Part A Inpatient claims, this subsection should be replaced by the Your

Benefit Periods subsection, described above.

POSITION

This subsection contains information of a fixed size. It does not vary in overall width or

length.

It begins (3.9˝, 0.94˝). This should top align with the How to Check This Notice

subsection on the left column. It is one-column or 259 points in width and 139 points in

height.

FORMATTING

[GR 2.1] black rule

[GL 14] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.1] body text of intro paragraph

[GR 6] space between paragraph

[TB 1.1] body text of bulleted paragraph

DYNAMIC RULES

This section should be printed only on Part B assigned and unassigned notices. The

content of the section is completely static.

CONTENT

Medicare Preventive Services

Medicare covers many free or low-cost exams and screenings to help you stay

healthy. For more information about preventive services:

• Talk to your doctor.

• Look at your “Medicare & You” handbook for a complete list.

• Create an account on Medicare.gov.

G. Your Messages from Medicare

POSITION

The position of this subsection varies depending on the extended family member: On

Part A Inpatient and combined MSNs, it follows the Your Benefit Periods subsection,

positioned 19 points from the baseline. On Part B assigned and unassigned MSNs, it

follows the Medicare Preventive Services subsection, with 19 points of space from the

baseline. On Hospice, Home Health (A) and (B), ‘B of A’, and DME MSNs, it has a

fixed start location at (3.9˝, 0.94˝), and is top aligned with the How to Check This Notice

subsection.

In all cases, it is one-column or 259 points in width with variable height from the

dynamic content, depending on the length of the CMS messages.

FORMATTING

[GR 2.1] black rule

[GL 9] glyph [TH 3] subsection header, center vertically to glyph

[GR 4.2] space after glyph

[TB 1.2] first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] first sentence [TB 1.1] body text

[GR 6] space between paragraph

[TB 1.2] first sentence [TB 1.1] body text

DYNAMIC RULES

This subsection can accommodate up to four messages from CMS. First and second

messages must be no longer than 200 characters (inclusive of spaces) and third and fourth

messages must be no longer than 250 characters (inclusive of spaces).

Current messages for this subsection, previously known as General Information

Messages from Medicare, can be found on the CMS website:

http://www.cms.gov/Medicare/Medicare-General-Information/MSN/index.html.

The first sentence, or the phrase up to the punctuation, will be bolded depending on the

message. Specific detail on where to bold will be provided by the CR of the variable

messages.