Page 14 - Cover Letter and Medicare evaluation for Mr. Rod Fallow

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. Medigap premiums for 67-year-old man in Santa Clara County $1,300 $1,550
Each plan's benefits relative to 100% coverage of all Medicare gaps 70.7% 85.6%

Coverage Area 2021 Coverage Gap
$371 daily co-pay for days 61-90;
Part A Hospital Co-Insurance $742 daily co-pay for days 91-150; All plans You pay You pay
nothing
nothing
cover 365 additional days.
Part A Skilled Nursing Facility A $185.50 daily co-payment for days 21-100 in
Co- Not covered Not covered
Insurance a skilled nursing facility
Part A Hospice Care Co- 5% co-insurance for respite care;
Insurance You pay
or Co-Payment $5 co-payment for inpatient drugs nothing 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

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

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

Medicare does not cover medical care outside
Foreign Travel the United States. But the seven Medigap
Emergencies** plans indicated do offer some coverage for Not covered Not covered
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, with a $250 deductible and a $50,000 lifetime limit.

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