Page 17 - APPENDICES for Steve Dickhaus

2020 Medigap Policy Coverage in Minnesota

50% $20 & $50 High
50% 75% Part A Copay for
Extended Deductible
Basic Deductible Part B
Basic
Similar Similar Similar to Similar to Similar to
to plan K to plan L plan M plan N plan F
Annual Out-of-
Pocket Limit 2020 None $1,000 $5,880 $2,940 None None $2,340*
Part A Deductible 100% if rider
purchased 100% 50% 75% 50% 100% 100%*
Part A Coinsurance 100% 100% 100% 100% 100% 100% 100%*

Skilled Nursing
Facility Coinsurance 100% 100% 50% 75% 100% 100% 100%*
For days 21 - 100
Part B Deductible** 100%
Eligible before if rider 100% - - - - 100%*
1/1/2020 purchased
Part B Deductible**
Newly eligible on or - - - - - - -
after 1/1/2020
Part B Coinsurance $20 & $50
100% 100% 50% 75% 100% 100%*
copays
Part B Excess** 100%
if rider 100% - - - - -
purchased
Medicare
Preventive Care 100% 100% 100% 100% 100% 100% 100%*
Preventive Services 100% up to
Not Covered by $120 if rider 100% up to - - - - -
$120
Medicare purchased
Foreign Travel -
Emergency 80% 80% - - 80% 80% 100%*
Foreign Travel -
Hospital and Medical - 80% - - - - -
Expenses and Supplies

*You must pay for the Medicare-covered costs up to $2,340 before the plan pays. This is a high-deductible plan.
**Beginning January 1, 2020, coverage for the Part B deductible is not available for newly eligible Medicare
beneficiaries. Newly eligible people include those who turn 65 or become eligible due to age, disability or ESRD on
or after January 1, 2020. The Part B deductible does not count toward the excess charges.

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2020 Medigap Policy Coverage in Minnesota 19