Page 2 - Cover Letter and Evaluation for Susan Church

PPO plans can sometimes be good choices if only one or even two of your doctors are not in the
network, so long as they are doctors you don’t go to very often and who do not administer
expensive treatments. Since several of your providers are out-of-network, though, enrolling in
one of the Wellcare Advantage plans may involve quite a bit of risk.

The next three Advantage plans with the lowest costs for your drugs are all sponsored by
Humana. One of these plans is an HMO and the other two are PPOs. None of these three plans
have premiums for their medical and prescription drug coverage, although one of the PPO plans
does have a $1,000 deductible, as discussed below.

People often wonder how an Advantage plan can make a profit if it doesn’t charge any
premiums. The answer is that when someone enrolls in an Advantage plan, Medicare pays the
plan a monthly amount, which can be $900 a month or more, to provide that person’s care.
Advantage plans are required to cover the same services that Medicare does, but they do not
have to cover every specific product, and they can charge different amounts than Medicare
charges so long as their overall benefit package is as good as Medicare’s.

Shown below are brief summaries of the three Advantage plans that are compared in your
evaluation. All of your providers with the possible exception of Karen Hannah are in these
plans’ networks (it’s likely that she is also because she works for Atlanta Behavioral Health).
Complete benefit summaries of each of these plans can be found in the appendices.

1) The Humana Gold Plus HMO Plan (H4141-015). This plan has several good features,
including patients’ ability to go to a network specialist without first getting a referral
from their primary care physicians. And for an HMO, it has a very large network of more
than 19,000 providers (a provider can be a doctor, physical therapist, clinic, hospital,
etc.). Its Medicare quality rating is 3.5 stars (out of a possible 5), an average score.

It also has some benefits for routine vision and dental care, which are not covered by
Medicare. Dr. Paladines is listed as a Humana dentist, but it’s possible he is not a
covered provider with this plan. You can verify this with his office or with the Humana
plan, whose phone number is shown on pages 2-3. Another solid benefit is that there is
no co-payment required when you go to your primary care doctor, so long as he or she
in the network. Co-payments for office visits to specialists range between $10 and $40.

This plan has a $5,900 out-of-pocket limit for medical services (not including Rx drugs),
which is fair or slightly below average for an Advantage HMO plan. And as you know, in
an HMO if you go to a provider who is not in the network, you will pay the full cost
unless it’s an emergency. Before enrolling in this plan, then, you should verify with your
providers offices that they are still in this plan’s network. This plan’s benefit details are
listed in Appendix B2.

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