Page 10 - Evaluation for John Shartle

Core Benefits
Medigap Plan Comparisons: This chart shows how much cost-sharing 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 A B
more than 100 days a skilled nursing facility, and so on.

Estimated annual premiums for 71-year-old man in Montgomery County, MD $1,650 $2,200
Estimated annual premiums for 71-year-old man in Sussex County, DE $1,375 $1,825

Coverage Area 2017 Coverage Gap
$329 daily co-pay for days 61-90;
Part A Hospital Co-Insurance $658 daily co-pay for days 91-150; You pay You pay
nothing
nothing
All plans cover 365 additional days.
Part A Skilled Nursing Facility Co- A $164.50 daily co-payment for days 21-100 in a
Insurance skilled nursing facility Not covered Not covered

Part A Hospice Care Co-Insurance 5% co-insurance for respite care; You pay
or Co-Payment $5 co-payment for prescription drugs nothing You pay
nothing
Part A Hospital Deductible The $1,316 first-day deductible You pay $1,316

Part B Deductible In 2017 the Part B deductible is $183 You pay $183 You pay $183

20% of Medicare-approved amounts for most
Part B Co-Insurance or Co- services covered by Part B after the $183 You pay You pay
Payment nothing nothing
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 average annual premiums are based on your state insurance department's Medigap comparisons and other
sources. Some estimates may be out of date, and you should use them only as starting points in finding companies that have
low premiums.

**Plans C, D, F, G, M, and N include benefits for foreign travel emergencies. These plans 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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