Page 5 - Cover Letter and Evaluation for Mr. Fred Falten

out-of-pocket limits. The two plans in your evaluation have out-of-pocket limits of $7,050
(Martin’s Point) and $6,700 (Humana Choice). And the Humana Choice PPO Plan’s out-of-
pocket limit jumps to $8,500 if you include out-of-network services. While it’s unlikely you
would spend this much in a given year, there are situations in which you could easily spend
more in either of these Advantage plans than you would with a comprehensive Medigap policy.
For more information about how Advantage plans work, see page 9 of your evaluation.

The two Advantage plans compared in your evaluation are 1) the Martin’s Point Generations
Advantage Prime HMO Plan with a Point-of-Service (POS) option; and 2) the Humana Choice
PPO Plan. Both these plans have high Medicare quality ratings, as well as either zero or very low
costs for the drugs you take. As noted above, all your physicians are listed in the Martin’s Point
plan’s network, but Dr. Dietz is not listed in the network of the Humana Choice plan. Again, you
should verify with your doctors’ offices that they still accept the plan you want to enroll in.

Both plans offer some dental, vision, and hearing coverage, although the Humana Choice PPO
Plan charges an additional premium for its dental coverage. And before enrolling in either plan,
you might verify with your dentist and optometrist/ophthalmologist that they accept this
coverage. Here are brief summaries of these two plans.

1) The Martin’s Point Generations Advantage Prime HMO-POS plan. This is one of
only 21 Advantage plans in the country that have a five-star quality rating from
Medicare (there are more than 3,500 Advantage plans nationwide). The ratings,
which are based on plans’ medical quality and customer satisfaction, are considered
good measures of a plan’s overall merit.

This plan’s point-of-service option allows patients to see out-of-network doctors,
preferably with the approval of their in-network primary care physician. And the
plan does restrict its coverage for many procedures (such as elective surgeries),
which it requires to be performed by network doctors and in network hospitals.

Also, out-of-network costs are higher. If you go to a network primary care doctor, for
example, you will not have a co-payment for an office visit, but if you go to an out-
of-network primary care doctor, you will have a $35 co-payment. For office visits to
specialists, you’ll pay $40 to see a network doctor and $55 if you go to a specialist
who is not in the network. This plan also has some coverage for medical
emergencies while traveling to other countries, which is unusual for an Advantage
plan. Perhaps its weakest point is its $7,050 out-of-pocket limit. This plan’s benefit
summary is in Appendix C2.

2) The Humana Choice PPO Plan. This plan has an above-average Medicare quality
rating of four stars. Its network appears to be smaller than the Martin’s Point
network, and Dr. Dietz, who practices in another state, is not listed as a network
provider. When you see him, you’ll have a $65 co-payment for an office visit and
could pay as much as 30% of the cost for some treatments and tests.

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