Plain-language bench

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Notice of Medicare Non-Coverage (NOMNC)

Centers for Medicare & Medicaid Services · source: Form CMS-10123-NOMNC, English, effective January 2025, expires 11/30/2027 · 28 critical facts of 34

Placeholders in the agency's template were filled with made-up values; see the notice's source file in the repo.

Rewrites

Haiku, grade 6: 27 of 28 critical facts kept · grade 6.8

What the judge found lost or changed

The rewrite

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 931-555-0163 **Notice: Medicare Will Stop Paying for Your Home Health Care** Patient name: Walter Pruitt **Medicare will stop paying for your home health care on Friday, March 14, 2025.** Your provider or health plan decided that Medicare will probably not pay for your home health care after that date. If you keep getting care after that date, you may have to pay for it yourself. **Your right to appeal** You have the right to appeal this decision. An appeal means asking an independent reviewer to look at it again. - If you appeal, your care will keep going while the review happens. - The reviewer will ask for your opinion. You do not have to write anything down, but you can if you want to. - The reviewer will also look at your medical records and other information about your care. - After you ask for an appeal, you will get a written letter that explains in detail why your care coverage should end. - If the reviewer agrees that Medicare should stop paying, neither Medicare nor your health plan will pay for your care after March 14, 2025. - If you stop getting care by March 14, 2025, you will not have to pay for it. **How to ask for an appeal right away** - Ask as soon as you can. Your request must be made no later than noon on the day before March 14, 2025. - Send your request to your Quality Improvement Organization, or QIO. A QIO is the independent reviewer that Medicare approves. - Call Midsouth Quality Review at 1-888-555-0142 to ask for an appeal or to ask questions. - If you miss the deadline, you may still have the right to appeal. **What happens next** - The QIO will tell you its decision as soon as possible. This is usually within two days after March 14, 2025. - If you have a Medicare health plan, the QIO will usually tell you its decision by March 14, 2025. - To learn more, call Midsouth Quality Review at 1-888-555-0142. **Please sign below to show you got this notice and understand it.** I have been told that my care coverage will end on the date in this notice. I know that I can appeal this decision by contacting my QIO. Signature of Patient or Representative: ____________________ Date: ____________ **Other rights** You can get this information in other formats, such as large print, Braille, or audio. You also have the right to file a complaint if you think you were treated unfairly because of who you are. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
Sonnet, grade 6: 26 of 28 critical facts kept · grade 5.3

What the judge found lost or changed

The rewrite

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Phone: 931-555-0163 **Notice: Medicare Will Stop Paying for Your Home Health Care** **Patient name:** Walter Pruitt **Medicare will stop paying for your home health care on Friday, March 14, 2025.** Your care provider or health plan believes Medicare will probably not pay for your home health care after this date. If you keep getting care after this date, you may have to pay for it yourself. **You have the right to appeal** You can say no to this decision. This is called an appeal. Here is what that means: - An outside doctor or expert will review your case right away. This person does not work for your provider or plan. - Your care will keep going while the review is happening. - The reviewer will want to hear what you think. You do not have to write anything down. You can if you want to. - The reviewer will also look at your medical records and other facts about your case. - After you ask for an appeal, you will get a letter. It will explain in detail why your care should end. - If the reviewer agrees that Medicare should stop paying, then Medicare and your plan will not pay for care after March 14, 2025. - If you stop your care by March 14, 2025, you will not owe money for it. **How to ask for an appeal right away** - Ask as soon as you can. - The last time you can ask is **noon on Thursday, March 13, 2025**. That is the day before your coverage ends. - To ask, call the Quality Improvement Organization. We will call it the QIO. The QIO is a group that Medicare trusts to review these decisions. - Your QIO is **Midsouth Quality Review**. Their phone number is **1-888-555-0142**. You can also call this number if you have questions. - If you miss the deadline, you may still be able to appeal. Call the QIO to find out. **What happens next** - The QIO will tell you its decision as soon as it can. This is usually within two days after March 14, 2025. - If you are in a Medicare health plan, the QIO will usually tell you by March 14, 2025. - To learn more, call Midsouth Quality Review at 1-888-555-0142. **Please sign below.** Your signature means you got this letter and understand it. It means you know that: - Your coverage will end on the date above. - You can appeal by calling the QIO. Signature of patient or person acting for the patient: ____________ Date: ____________ **Help and fairness** You can ask for this letter in another form, such as large print, Braille, or audio. If you feel you were treated unfairly, you can file a complaint. To learn more: - Go to Medicare.gov/about-us/accessibility-nondiscrimination-notice - Or call 1-800-MEDICARE (1-800-633-4227) - If you use a TTY, call 1-877-486-2048
Opus, grade 6: 24 of 28 critical facts kept · grade 6.0

What the judge found lost or changed

The rewrite

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 931-555-0163 ## Notice That Medicare Will Stop Paying Patient name: Walter Pruitt ## Medicare Will Stop Paying for Your Home Health Care After Friday, March 14, 2025 Your care team or your health plan has decided that Medicare will probably not pay for your home health care after Friday, March 14, 2025. If you keep getting care after that day, you may have to pay for it yourself. ## You can ask for this decision to be checked - You have the right to say you disagree with this decision. This is called an **appeal**. - If you appeal, a reviewer who does not work for us or your health plan will look at your case right away. - Your care will keep going while the reviewer looks at your case. - The reviewer will ask what you think. You do not have to write anything down, but you can if you want to. - The reviewer will also look at your medical records and other information about your care. - After you ask for an appeal, you will get a letter that explains in detail why we think Medicare should stop paying. - If the reviewer agrees that Medicare should stop paying, then Medicare and your health plan will not pay for care you get after March 14, 2025. - If you stop your care by March 14, 2025, you will not have to pay for care after that day. ## How to ask for a fast appeal - Ask as soon as you can. - **You must call by 12:00 noon on Thursday, March 13, 2025.** This is the day before your Medicare coverage ends. - Call the group that does these reviews for Medicare. This group is called a **Quality Improvement Organization (QIO)**. Your QIO is: **Midsouth Quality Review: 1-888-555-0142** - Call this number to appeal or to ask questions. - If you miss the deadline, you may still be able to appeal in other ways. Call the QIO to find out. ## What happens next - The QIO will tell you its decision as soon as it can. Most of the time, it will tell you no later than 2 days after March 14, 2025. - If you have a Medicare health plan, the QIO will usually tell you by March 14, 2025. - To learn more, call Midsouth Quality Review at 1-888-555-0142. ## Please sign below Signing shows that you got this letter and understand it. I have been told that Medicare will stop paying for my care after the date on this letter. I know I can appeal by calling my QIO. Signature of Patient or Person Signing for Patient: ____________ Date: ____________ ## Other help You can get this letter in other forms, such as large print, Braille, or audio. If you feel you have been treated unfairly, you can make a complaint. To learn more: - Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice - Or call 1-800-MEDICARE (1-800-633-4227) - If you use TTY, call 1-877-486-2048
Sonnet, grade 4: 26 of 28 critical facts kept · grade 4.3

What the judge found lost or changed

The rewrite

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Phone: 931-555-0163 **Notice: Medicare Will Stop Paying for Your Care** **Patient:** Walter Pruitt **Medicare will stop paying for your home health care on Friday, March 14, 2025.** We think Medicare will probably not pay for your home health care after this day. If you keep getting care after this day, you may have to pay for it yourself. **You can ask for a review** You do not have to accept this decision. You can ask for an appeal. An appeal means a team that does not work for us will look at the decision again. - Your care will keep going while the team looks at it. - The team will want to hear what you think. You do not have to write anything down. But you can if you want to. - The team will also read your medical records. - After you ask for an appeal, you will get a letter. It will explain why we think your care should stop. - Sometimes the team agrees with us. If that happens, Medicare and your health plan will not pay for your care after March 14, 2025. - If you stop your care by March 14, 2025, you will not owe any money for it. **How to ask for a review** - Ask as soon as you can. - You must ask before **noon on Thursday, March 13, 2025**. That is the day before your coverage ends. - Call the review team. Their name is Midsouth Quality Review. They are picked by Medicare. - Their phone number is **1-888-555-0142**. - You can call this number if you have any questions, too. - If you miss the deadline, you may still be able to ask for a review. Call them to find out. **What happens next** - The review team will tell you what they decide. This is usually within two days after March 14, 2025. - If you are in a Medicare health plan, they will usually tell you by March 14, 2025. - Call 1-888-555-0142 if you want to know more. **Please sign below.** Your signature shows that you got this letter and understand it. It means: "I know my care will stop being paid for on the date in this letter. I know I can ask for a review by calling the review team." Signature of patient or helper: ____________ Date: ____________ **Need this letter in a different form?** You can get this letter in large print, Braille, or audio. You can also make a complaint if you feel you were treated unfairly because of who you are. - Go to Medicare.gov/about-us/accessibility-nondiscrimination-notice - Or call 1-800-MEDICARE (1-800-633-4227). - If you use a TTY, call 1-877-486-2048.
Sonnet, grade 8: 26 of 28 critical facts kept · grade 6.8

What the judge found lost or changed

The rewrite

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 Phone: 931-555-0163 **Notice: Medicare Will Stop Paying for Your Home Health Care** Patient: Walter Pruitt **Medicare will stop paying for your home health care on Friday, March 14, 2025.** Your home health provider or health plan has decided that Medicare most likely will not pay for your home health care after this date. If you keep getting care after March 14, you may have to pay for it yourself. **You can appeal this decision** You have the right to appeal. An appeal means an outside medical expert will review the decision quickly. Your care will keep going while the review takes place. - The reviewer will ask what you think. You do not have to write anything down, but you can if you want to. - The reviewer will also look at your medical records and other helpful information. - After you ask for an appeal, you will get a letter. It will explain in detail why your care should end. - If the reviewer agrees that Medicare should stop paying, neither Medicare nor your health plan will pay for care after March 14. - If you choose to stop your care by March 14, you will not owe money for it. **How to ask for a fast appeal** - Ask as soon as you can. **You must ask by noon on Thursday, March 13, 2025**, which is the day before your coverage ends. - Contact your Quality Improvement Organization (QIO). The QIO is an outside group that Medicare picks to review these decisions. - If you miss the deadline, you may still be able to appeal. - To appeal or ask questions, call your QIO, Midsouth Quality Review, at **1-888-555-0142**. **What happens next** - The QIO will tell you its decision as soon as it can. This is usually no later than two days after March 14. If you are in a Medicare health plan, you will usually hear by March 14. - To learn more, call Midsouth Quality Review at **1-888-555-0142**. **Please sign below** Your signature shows that you got this letter and understand it. It means you know your coverage will end on March 14, and that you can appeal by calling your QIO. Signature of patient or representative: ____________ Date: ____________ **Help and your rights** You can get this information in other formats, such as large print, Braille, or audio. You can also file a complaint if you think you were treated unfairly because of who you are. For more information, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
Sonnet, grade 6, 'keep everything' prompt: 28 of 28 critical facts kept · grade 6.4

The judge found nothing lost.

The rewrite

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Phone: 931-555-0163 ## Notice That Medicare Will Stop Paying for Your Care **Patient name:** Walter Pruitt ## Medicare will stop paying for your home health care on Friday, March 14, 2025. Your care provider or health plan thinks Medicare most likely will not pay for your home health care after this date. If you keep getting care after March 14, 2025, you may have to pay for it yourself. ## You have the right to appeal An appeal means you ask for this decision to be looked at again. You have the right to appeal the decision to stop Medicare coverage. - An outside medical expert will review your case right away. This expert does not work for us. - Your care will keep going while the review is happening. - The reviewer will ask what you think. You do not have to write anything down. But you have the right to write down your thoughts if you want to. - The reviewer will also look at your medical records and any other facts that matter. - After you ask for an appeal, you will get a notice. It will explain in detail why your coverage should end. - If the reviewer agrees that Medicare should stop paying on March 14, 2025, then neither Medicare nor your health plan will pay for care after that date. - If you stop your care by March 14, 2025, you will not have to pay for it. ## How to ask for a fast appeal - Ask as soon as you can. - **Your deadline is noon (12:00 p.m.) on Thursday, March 13, 2025.** That is the day before your coverage ends. - Make your request to your Quality Improvement Organization. This is called a "QIO." The QIO is the outside reviewer that Medicare approves. - If you miss the deadline, you may still have the right to appeal. - To appeal, or if you have questions, call your QIO: **Midsouth Quality Review: 1-888-555-0142** ## What happens next - The QIO will tell you its decision as soon as it can. This is usually no later than 2 days after March 14, 2025. - If you are in a Medicare health plan, the QIO will usually tell you its decision by March 14, 2025. - To learn more, call the QIO at **1-888-555-0142**. ## Please sign Sign below to show that you got this notice and understand it. "I have been told that my coverage will end on the date on this notice. I know I can appeal by contacting my QIO." Signature of patient or representative: ____________________ Date: ____________________ ## Help and your other rights - You have the right to get this information in a form that works for you. This includes large print, Braille, or audio. - You have the right to make a complaint if you think you were treated unfairly because of who you are. - To learn more, go to **Medicare.gov/about-us/accessibility-nondiscrimination-notice**. Or call **1-800-MEDICARE (1-800-633-4227)**. - If you use a TTY, call **1-877-486-2048**.
Rewrite tool (Sonnet, grade 6): 28 of 28 critical facts kept · grade 7.2

The judge found nothing lost.

The rewrite

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Phone: 931-555-0163 # Notice of Medicare Non-Coverage **Patient name:** Walter Pruitt ## Your Medicare coverage for home health care is ending Medicare coverage of your home health services from Riverbend Home Health will end on **Friday, March 14, 2025**. Your provider or health plan decided that Medicare probably will not pay for your home health services after that date. You may have to pay for any services you get after March 14, 2025. ## You have the right to appeal You can appeal the decision to end your Medicare coverage. If you appeal: - You get an independent medical review right away. - Your services continue while the appeal is going on. - The independent reviewer will ask for your opinion. - You do not have to write anything down. But you have the right to prepare a written statement if you want to. - The reviewer will also look at your medical records and other useful information. - After you ask for an appeal, you will get a notice. It will explain in detail why your coverage should end. ## What an appeal could mean for your costs - If the independent reviewer agrees that your coverage should end, neither Medicare nor your plan will pay for services after March 14, 2025. - If you stop services by March 14, 2025, you will not have to pay for them. ## How to ask for an immediate appeal - **Ask as soon as you can.** - To be on time, you must ask by **noon on Thursday, March 13, 2025**. That is the day before your coverage ends. - Make your request to your Quality Improvement Organization (QIO). The QIO is the independent reviewer that Medicare has approved. - If you miss the deadline, you may still have appeal rights. - To appeal, or if you have questions, call the QIO: **Midsouth Quality Review: 1-888-555-0142** ## What happens next - The QIO will tell you its decision as soon as it can. This is usually no later than two days after March 14, 2025. - If you are in a Medicare health plan, the QIO usually tells you its decision by March 14, 2025. - To learn more, call Midsouth Quality Review at 1-888-555-0142. ## Sign and date below Sign to show that you got this notice and understand it. "I have been told that my coverage will end on the date on this notice. I know I can appeal by contacting my QIO." Signature of patient or representative: ____________________ Date: ____________________ ## Your rights - You have the right to get this information in a format you can use. This includes large print, Braille, or audio. - You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination). - To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). - If you use a TTY, call 1-877-486-2048.

The original letter

Highlighted: the passages behind the 28 critical facts.

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 931-555-0163 ## Notice of Medicare Non-Coverage Patient name: Walter Pruitt ## Medicare Coverage of Your Current Home Health Services Will End on Friday, March 14, 2025 Your provider and/or health plan determined that Medicare probably won’t pay for your home health services after the above date. You may have to pay for any services you get after this date. ## Your right to appeal this decision - You have the right to appeal the decision to end Medicare coverage of your services. This means you’ll get an independent medical review right away. Your services will continue during the appeal. - If you choose to appeal, the independent reviewer will ask for your opinion. You don’t have to prepare anything in writing, but you have the right to do so. The reviewer also will look at your medical records and/or other relevant information. - Once you ask for an appeal, you’ll get a notice with a detailed explanation about why your service coverage should end. - If the independent reviewer agrees Medicare coverage for your services should end, neither Medicare nor your plan will pay for these services after the above date. - If you stop services by the above date, you’ll avoid financial liability. ## How to ask for an immediate appeal - Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date. - Make your request to your Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare. - If you miss the deadline to ask for an immediate appeal, you may still have appeal rights. - Call your QIO at Midsouth Quality Review, 1-888-555-0142, to appeal, or if you have questions. ## What happens next - The QIO will let you know its decision as soon as possible, generally no later than two days after the effective date above. If you’re in a Medicare health plan, the QIO generally will let you know its decision by the effective date above. - Call your QIO at Midsouth Quality Review, 1-888-555-0142, to learn more. Sign below to show you received and understand this notice. I’ve been notified that coverage of my services will end on the date on this notice, and that I can appeal this decision by contacting my QIO. Signature of Patient or Representative: ____________ Date: ____________ You have the right to get your information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.