Page 17 - Cover Letter and Medicare Evaluation for Dorothy Smith

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

High
C D F G Deductible K L M N
Plan F or G*

$1,875 $1,850 $1,900 $1,650 $900 $925 $1,350 $1,675 $1,350

99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay You pay You pay
You pay You pay $200 a day $100 a day nothing You pay
nothing nothing After you nothing
have paid You pay You pay
the plan's 2.5% & 1.25% &
You pay $2,700 $2.50 $1.25
nothing deductible, You pay You pay You pay
You pay you will $800 $400 $800
You pay nothing You pay have no You pay You pay You pay You pay
$226 $226 further cost- $226 $226 $226 $226
sharing for You pay $20 for
Medicare- 10% of You pay 5% doctor's
You pay covered Medicare- of Medicare- You pay office visits;
nothing approved nothing
services. approved $50 for ER
You pay amount amount visit
nothing

Not Not Not
covered covered Not covered Not covered Not covered covered

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

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

* High 2023 high-deductible amount = $2,700
Deductible
F and G are 2023 Out-of-Pocket Limit $6,940 $3,470
identical

Out-of-pocket limits do not include plan premiums. Nor do they apply to services that are not covered. In Plans K and L,
for example, the Part B deductible is not covered. Thus any money you spend for the Part B deductible does not count
toward the OOP limit.

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