Page 13 - Cover letter and Medicare evaluation for Hans Burkhardt

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

G
D G (High K L M N
Deductible)

$1,625 $1,700 $900 $975 $1,275 $1,600 $1,300
97.1% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%

You pay
You pay nothing
nothing

You pay $92.75 a You pay $46.37 You pay
You pay You pay day a day nothing You pay
nothing nothing After you have nothing
paid the plan's You pay 2.5% & You pay 1.25%
$2,370 up to $2.50 & up to $1.25
deductible,
you will have You pay $742 You pay $371 You pay $742
no further cost-
You pay $203 You pay $203 sharing for You pay $203 You pay $203 You pay $203 You pay $203
Medicare- You pay 10% of You pay 5% of
You pay covered Medicare- Medicare- You pay $20 for doctor's
office visits; $50
nothing services. approved approved nothing for an ER visit
You pay amount amount
nothing

Not covered Not covered Not covered Not covered Not covered

Some Some Some Some Some
coverage* coverage* coverage* Not covered Not covered coverage* coverage*

You pay You pay You pay You pay 10% of You pay 5% of You pay You pay
nothing nothing nothing cost cost nothing nothing

High Deductible in 2021 = $2,370

2021 out-of-pocket limits $6,220 $3,110

***Out-of-pocket limits do not include plan premiums. Nor do they include any amounts that you pay for services that
are not covered by the plan. As an example, none of the plans cover the Part B deductible, and so any money you
spend toward the Part B deductible will not count toward the plan's out-of-pocket limit.

7