Page 11 - Cover Letter and Evaluation for Marilyn Shelton

Marilyn's estimated costs in each plan

Plan name Medigap Plan G Medigap Plan N Medigap Plan L Medigap Plan K

Toll-Free Number NA NA NA NA
Minimum costs (health plan premiums + Rx drug costs)
lity ratings from
Medicare web site
2019 standard Part B
premium of $135.50 a $1,626 $1,626 $1,626 $1,626
month*

Medigap estimated
annual premiums $1,850 $1,525 $1,450 $1,000

Rx mail-order costs
(premiums + co- $1,198 $1,198 $1,198 $1,198
payments)

Total $4,674 $4,349 $4,274 $3,824

Part B deductible $185** $185** $185** $185**

Part A and Part B out-of-pocket costs (2019 costs)

Part A: The amount you No cost for No cost for
will pay if you are Medicare-covered Medicare-covered You will pay $341 You will pay $682
hospitalized hospitalization hospitalization

Part B: The amount you See below for cost-

will pay for most $0 after $185 Part B sharing amounts 5% of Medicare- 10% of Medicare-
Medicare-covered deductible is paid after Part B $185 approved cost for approved cost for
most services
most services
outpatient services deductible is paid
Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays No co-pays for up to $20 for
Medicare-covered Medicare-approved You will pay 5% of
In-Network Specialist doctors' office visits doctor's office visit; the Medicare- You will pay 10% of
the Medicare-
Co-Pays after $185 Part B $50 for emergency approved amount approved amount

de
Out-of-Network ductible is paid room visit
Co-Pays
*This is 2019 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2019 is $185.

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