This is an archived document and does not contain the most current information for this topic. Use this document for reference only.

Appendix C

Medicare Cost Sharing Amounts (Archive)

This appendix provides cost sharing amounts for Medicare.

Medicare Part A Cost Sharing Amounts

Cost Type	2021	2022
Premium	Varies	Send SVES
Deductible	$1,484	$1,556
Hospital Coinsurance days 61-90	$371	$389
Hospital Coinsurance days 91-150	$742	$778
Skilled Nursing Facility Coinsurance days 1-20	$0	$0
Skilled Nursing Facility Coinsurance days 21-100	$185.50	$194.50

Medicare Part B Cost Sharing Amounts

Cost Type	2021	2022
All Other Premium Amounts	Varies	Send SVES
Deductible	$203	$233
MSHO and SNBC plans that will pay the portion listed of the Medicare Part B Premium	None	None

Medicare Part D Cost Sharing Amounts

For information about which Medicare Part D plans in Minnesota are benchmark plans, refer to the Resources section in ONEsource for the Amounts in Excess of Medicare Part D Benchmark to Apply as Medical Expense document. The document also provides the amount a person pays out of pocket for non-benchmark plans.

Standard Benefit Information

Cost Type	2021	2022
Premium	Varies	Varies
Annual Deductible	$445	$480
Coinsurance Costs	25% of drug costs between $445.01 and $4,130 (Cap of $6,550)	25% of drug costs between $480.01 and $4,430 (Cap of $7,550)
Coverage Gap Costs	100% of costs between the initial coverage limit based on drug costs between $4,130.01 and $6,550. 75% discount on brand name drugs 75% discount on generic drugs	100% of costs between the initial coverage limit based on drug costs between $4,430.01 and $7,550. 75% discount on brand name drugs 75% discount on generic drugs
Copayments	$3.70 generic drugs $9.20 brand name drugs	$3.95 generic drugs $9.85 brand name drugs

Extra Help Full Subsidy Information

Cost Type	2021	2022
Premium	$0	$0
Annual Deductible	$0	$0
Coinsurance Costs	None	None
Coverage Gap Costs	None	None
Copayments	< 100% FPG $1.30 generic drugs $4.20 brand name drugs	< 100% FPG $1.35 generic drugs $4.00 brand name drugs

Extra Help Partial Subsidy Information

Cost Type	2021	2022
Premium	Sliding scale premiums	Sliding scale premiums
Annual Deductible	$92	$99
Coinsurance Costs	15%	15%
Coverage Gap Costs	None	None
Copayments	$3.70 generic drugs $9.20 brand name drugs	$3.95 generic drugs $9.85 brand name drugs