Page 2 - Cover Letter and Evaluation for Dr. Jim Fisgus

coverage. An Advantage HMO plan is probably not a viable choice for you because Dr.
DeMeester is out of state and you would not be covered when you see him unless it’s an
emergency. The two Medigap plans that are compared are Plan G and Plan N. These are both
popular plans and have solid coverage.

Your physicians’ network affiliations

All your doctors accept Medicare-approved rates, as shown in Appendix A. Some physicians
accept Medicare but not Medicare-approved rates. In those cases, they can charge up to 15%
more than the approved rates. In most cases, those additional charges are only a few dollars,
but for expensive treatments, they can be substantial. Medigap Plan G in your evaluation
covers that added 15% charge, but Plan N does not. In any event, this isn’t currently an issue
because your doctors all accept the approved rates.

Even though the Gensler PPO Plan and the Aetna Medicare Choice PPO Plan are both
sponsored by Aetna, they do not necessarily have the same doctors in their networks. Aetna
has multiple plans, and providers may select which, if any, of these plans they will accept. The
Aetna Medicare Choice PPO plan does not list Dr. Canceko (or Keck School of Medicine) in its
network, nor does it include Dr. DeMeester. And I don’t know which of your doctors may be in
the Gensler plan’s network.

In both these managed=care plans – the Gensler Aetna PPO Plan and the Aetna Medicare
Choice PPO Plan – your cost-sharing is substantially higher when you see doctors who are not in
network. And in the Gensler plan, your out-of-pocket risk is tripled when you go outside the
network. These plans are not good choices for people who routinely see out-of-network
providers.

Here’s an overview of each of the four options in your evaluation. Except for the Gensler plan’s
benefit summary that you sent me, the cost and coverage details of these options are shown in
the appendices.

1. The Gensler Aetna PPO Plan. Because this plan does not have Medicare’s underlying
catastrophic protections, it has high costs and risk. Your spousal coverage premiums are
$101.20 per bi-weekly pay period, or $2,631 a year, for medical and Rx drug benefits
combined.

Despite this stiff premium, you will pay 20% of the cost of most network outpatient
services, which is the same percentage that you would pay with Part B if you didn’t have
any supplemental coverage. And if you go outside the network, the percentage jumps to
40%, excluding preventive services (which are free in all of these options). If you are
hospitalized, you will pay 20% of the cost after a $500 co-pay, and the total could easily
turn out to be several thousand dollars.

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