Page 12 - Cover Letter and Medicare Evaluation for Diane Falten

Medigap Plan Comparisons: This chart shows how much cost-sharing Core Benefits
you will have in each Medigap plan. Not included are payments for
services that Medicare does not cover like routine dental/vision care,
hearing aids, benefits for more than 100 days a skilled nursing facility, A B
and so on.

Est. annual premiums for 72-year-old woman in Strafford County, NH $1,850 $2,400

Each plan's benefits relative to 100% coverage of all Medicare 70.7% 85.6%
Coverage Area 2021 Coverage Gap

$371 daily co-pay for days 61-90; You pay You pay
Part A Hospital Co-Insurance $742 daily co-pay for days 91-150; All plans nothing nothing
cover 365 additional days.

Part A Skilled Nursing Facility A $185.50 daily co-payment for days 21-100 in a Not covered Not covered
Co-Insurance skilled nursing facility

Part A Hospice Care Co- You pay
Insurance 5% co-insurance for respite care; nothing
or Co-Payment $5 co-payment for inpatient drugs You pay
nothing
You pay
Part A Hospital Deductible In 2021 the Part A deductible is $1,484 $1,484

Part B Deductible In 2021 the Part B deductible is $203 You pay $203 You pay $203

You pay You pay
20% of Medicare-approved amounts for most
Part B Co-Insurance or Co- services covered by Part B after the $203 nothing nothing
Payment
deductible is paid

In most states, providers who do not accept
assignment can charge up to 15% more than
Part B Excess Charges Not covered Not covered
Medicare-approved amounts. Three Medigap
plans cover these excess charges.

Medicare does not cover medical care outside
the United States. But the seven Medigap plans
Foreign Travel Emergencies** Not covered Not covered
indicated do offer some coverage for emergency
medical care in other countries.

You pay You pay
Blood First 3 pints of blood nothing nothing

*Estimated annual premiums are based in most cases on your state insurance department's Medigap premium
comparisons or on quotes from an actuarial firm. There can be large variations in premiums from one company to
another, and it's a good idea to get several current quotes.

**Plans C, D, F, G, M, and N include benefits for foreign travel emergencies. They cover 80% of cost of medical
emergencies while traveling in other countries. This coverage has a $250 deductible and a $50,000 lifetime limit.

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