Page 3 - Cover Letter and Evaluation for Dr. Jim Fisgus

In the Gensler plan the out-of-network penalties are more significant than in the Aetna
Medicare PPO Plan because the Gensler plan tracks in-network and out-of-network in
separate categories that do not cross-apply. Thus the $600 deductible for network
medical services and the $1,500 deductible for out-of-network services create a worst-
case $2,100 deductible.

Similarly, the $4,000 in-network out-of-pocket limit and the $8,000 out-of-network limit
could wind up, in an extreme and unlikely case, of being a $12,000 out-of-pocket limit.
The only positive is that this limit also includes prescription drug costs. As you know,
OOP limits do not include premiums, and therefore your true worst-case numbers are
$2,631 more than the $12,000 limit.

2. The Aetna Medicare Choice PPO Plan. This plan is similar in certain respects to the
Gensler plan, and it has an above-average quality rating of four stars from Medicare. In
Advantage plans, there are separate premiums for medical and for Rx drug coverage
(although you pay only the combined premium each month).

This plan’s combined premium is $81 a month -- $41.40 for health plan premiums and
$39.60 a month for Rx drug coverage. Because you take three inexpensive generic
drugs, the drug premium covers your co-pays and your annual total is the sum of your
monthly $39.60 payments.

This plan has a $750 medical deductible and a $6,700 out-of-pocket limit for network
services, which increases to $10,000 for in-and-out of network combined. Unlike the
Gensler plan, in and out-of-network costs both apply to the $10,000 OOP limit. And
there is only one deductible in this plan, not two as in the Gensler plan.

Another strong feature is that this plan has a network of more than 20,000 providers in
Riverside and San Bernardino Counties – providers can be doctors, hospitals, skilled
nursing facilities, clinics, etc. Appendix C2 is a summary of this plan’s costs and benefits.

Before describing the two Medigap plans in your evaluation, it might be helpful to list some
features that all Medigap policies share (you may already be aware of these). These policies can
be purchased during the first six months you have Part A and Part B without your having to
answer health-related questions.

But after that six-month period has past, in California and most other states if you want to
acquire a Medigap policy, you will likely have to answer questions about your health before
receiving a premium quote. And people who have serious health issues may not be able to
purchase a Medigap policy or upgrade from a less comprehensive to a more comprehensive
Medigap plan after this initial six-month period.

Perhaps the most desirable attribute of Medigap policies is the flexibility they offer. There are
no networks, and so you will be covered when you see any provider who accepts Medicare (as

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