Value Worksheet
Summit ElderCare Value Comparison Worksheet (pdf - 33KB)
| Current Estimated Expenses |
Monthly Expense |
| Medicare Premiums (this amount is deducted from your social security check) |
$__________ |
| Other health insurance premiums (this could include Medicare Advantage such as Fall on Senior Plan, individual supplemental plans or your monthly cost share of an employer sponsored retiree plan) |
$__________ |
| Out of pocket costs for prescription medications |
$__________ |
| Copayments |
$__________ |
| Coinsurance |
$__________ |
| Out of pocket costs for prescribed over the counter medications |
$__________ |
| Out of pocket expenses for copayments or coinsurance for visits to doctors offices or rehabilitation visits. |
| Primary care visits |
$__________ |
| Wellness visits |
$__________ |
| Specialist visits |
$__________ |
| Rehabilitation visits |
$__________ |
| Costs associated with medical visits not currently covered by an insurance plan (if any) |
$__________ |
| Specify |
$__________ |
| Specify |
$__________ |
| Copayments or deductibles for hospitalization expenses not covered by insurance. |
$__________ |
| Emergency room costs not covered by insurance. |
$__________ |
| Out of pocket costs for other medical supplies (e.g. dressings, equipment, colostomy supplies, etc.) |
$__________ |
| Attendance at an Adult Day Health Center (Average private pay cost is $35 to $75 per day plus transportation expenses. |
$__________ |
| Private Geriatric Case Management (varies by Provider) |
$__________ |
| In home assistance with (bathing/dressing, meal preparation, grocery shopping, housekeeping, and other activities of daily living) |
$__________ |
| In home assistance with nursing (i.e. dressing changes, Medication management) or other therapeutic services |
$__________ |
| In home assistance with companionship/supervision (Charges average $14 - $30 per hour) |
$__________ |
| Transportation to and from medical appointments |
$__________ |
| Other, please specify |
$__________ |
| Total current out of pocket expenses |
$ |
|
You can use this worksheet to compare your current out of pocket costs to your estimated change in out of pocket costs if you enroll in Summit ElderCare. |
SE 2008-13 R1 2/29/08