Page 15 - Cover Letter and Medicare evaluation for Mr. Rod Fallow

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

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

$1,925 $1,900 $1,950 $1,700 $975 $900 $1,400 $1,500 $1,450
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 After you $92.75 a day $46.37 a day nothing You pay
nothing nothing nothing
have paid You pay You pay
the plan's 2.5% & 1.25% &
You pay $2,370 $2.50 $1.25
nothing deductible, You pay You pay You pay
you will
You pay $742 $371 $742
You pay nothing You pay have no You pay You pay You pay You pay
further
$203 $203 $203 $203 $203 $203
cost-
sharing for You pay 10% You pay 5% $20 for
You pay Medicare- of Medicare- of Medicare- You pay doctor's
office
nothing covered approved approved nothing
services. amount amount visits; $50
You pay for ER visit
nothing

Not Not covered Not 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 10% You pay 5% You pay You pay
nothing nothing nothing nothing nothing of cost of cost nothing nothing

* High 2021 high-deductible amount = $2,370
Deductible F
and G are 2021 Out-of-Pocket Limit $6,220 $3,110
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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