Page 11 - Cover Letter and Evaluation for Mr. Fred Falten

Your estimated costs in each plan

Martin's Point
Plan name Medigap Plan F Medigap Plan N Generations Humana Choice PPO
Advantage Prime Plan
(HMO-POS)
Toll-Free Number NA NA (888) 640-4423 (800) 833-2364
Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
2021 Part B premium
($148.50 a month)* $1,782 $1,782 $1,782 $1,782
Health plan annual

premiums (Medigap $3,000 $2,450 $0 $0
premiums are estimates)
Plan medical/Part B
deductible** $0 $203 $0 $0

Rx drug costs for 9
months (mail-order) $212 $212 $0 $102

Total $4,994 $4,647 $1,782 $1,884

Part A and Part B out-of-pocket costs

Part A: The amount you $333 a day for days $325 a day for days
will pay if you are No cost No cost 1-5 in network; $0 1-5 in network; $0
hospitalized for days 6-90. thereafter

Part A: Care in a skilled $0 for days 1-20; $0 for days 1-20;
nursing facility No cost No cost $178 for days 21- $184 a day for days
100. 21-100.

Part B: Emergency care No cost No cost after Part B $90 co-pay $90 co-pay

(not including ambulance) deductible
Cost-sharing for doctors' office visits

=
In-Network Primary After Part B
Care Co-Pays deductible, $20 for $0 $0
In-Network Specialist No cost doctor's office visits

Co-Pays and $50 for $40 $45
Out-of-Network emergency room $35 for PCP; $55 for $20 for PCP; $65 for
visits
Co-Pays specialist specialist
*This is 2021 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2021 is $203; medical deductibles for Advantage plans vary.

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