Page 17 - Cover Letter and Evaluation for Steve DIckhaus

Minnesota-Only Plans Nationally Standardized Plans

Basic Plan (without riders) Extended Basic Plan Plan K Plan L Plan M Plan N

$1,800 $2,450 $1,100 $1,850 $2,000 $1,900
Your co-payments in each plan in 2020

You pay nothing You pay nothing You pay nothing You pay nothing

You pay nothing. Also,
You pay nothing skilled nursing care is fully You pay $80.50 You pay $40.25 You pay nothing You pay nothing
covered for 120 days per a day a day
benefit period (vs. 100 days
in Basic Plan) You pay 2.5% & You pay 1.25%
$2.50 & $1.25 You pay nothing You pay nothing

$1,408 unless you buy You pay $644 You pay $322 You pay $644 You pay nothing
rider*

You pay $198 You pay $198 You pay $198 You pay $198 You pay $198 You pay $198

You pay 10% of You pay 5% of Only costs are
Medicare- Medicare- $20 for doctor's
You pay nothing You pay nothing You pay nothing
approved approved office visits and
amount amount $50 for ER visits

up to 15% of Medicare- You pay nothing Not covered Not covered Not covered Not covered
approved charges*

You pay 20% of cost for
medical emergencies in You pay nothing Not covered Not covered Some coverage Some coverage
foreign countries

You pay 10% of You pay 5% of
You pay nothing You pay nothing You pay nothing You pay nothing
cost cost
OOP Limit** $5,880 $2,940 NA NA
*Optional riders to cover Part A deductible and 15% excess charge are available at an additional cost. As indicated in the
footnote on Page 6, Minnesota medical providers are not allowed to add the 15% excess charges, so this rider would not be of
any value in Minnesota (but could be in other states)

** In Minnesota there are three Medigap plans that have out-of-pocket limits -- the Extended Basic plan and nationally
standardized Plans K and L. OOP limits apply only to services that the plans cover. .

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