Page 15 - Cover letter and evaluation for Marcelle Nesci

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

F
C D F G (High K L M N
Deductible)

$2,980 $2,790 $3,000 $1,600 $1,100 $1,200 $2,175 $2,550 $2,200

99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay You pay You pay
You pay You pay $85.25 a day $42.63 a day nothing You pay
nothing nothing After you nothing
have paid You pay 2.5% You pay
You pay the plan's & $2.50 1.25% &
nothing $2,300 $1.25
deductible, You pay
You pay you will You pay $682 You pay $341 $682
nothing have no
You pay $185 You pay further cost- You pay $185 You pay $185 You pay You pay
$185 sharing for $185 $185
Medicare- You pay 10% You pay 5% of Only costs are
You pay covered of Medicare- Medicare- You pay $20 for doctor's
nothing services. approved approved nothing office visits; $50
amount amount for an ER visit
You pay
nothing

Not covered Not covered Not covered Not covered Not covered Not covered

Some Some Some Some Some Some Some
coverage* coverage* coverage* coverage* coverage* Not covered Not covered coverage* coverage*

You pay You pay You pay You pay You pay You pay 10% You pay 5% You pay You pay
nothing nothing nothing nothing nothing of cost of cost nothing nothing
2019 high-deductible amount = $2,300

2019 Out-of-Pocket Limit*** $5,560 $2,780

*** Out-of-pocket limits do not include plan premiums. Nor do they apply to services that are not covered. In Plans K and L, for example,
the Part B deductible is not covered. Thus any money you spend for the Part B deductible does not count toward the OOP limit.

7