| Part A Hospital Services | F | G |
|---|---|---|
| The Part A deductible is $1632 per benefit period A benefit period starts when you are admitted to a facility and ends 60 days after you last received inpatient care at any facilityPart A Deductible ($1632) |
 |
|
|
|
|
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
| Skilled nursing facility coinsurance | |
|
| 3 Pints of (unreplaced) blood | |
|
| Part B Services | F | G |
| Part B Annual Deductible ($240) | |
|
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
| Doctors who do not take Medicare Assignment can charge 15% above what medicare allows Some Medicare Supplement plans cover that extra 15%Part B Excess Charges |
|
|
| Additional Features | F | G |
| Out of Pocket Limit | NA | NA |
| Hospice coverage | |
|
| Foreign Travel Emergency | |
|
| Monthly Rates & Brochures | F | G |
| Anthem | S: 350.48 I: Additional benefits included with Anthem Innovative plan rider
|
255.09 |
| Blue Shield eff 7/1/2024 | 351.00 | S: 296.00 Extra Rider
E: 311.00 |
| UHC eff 6/1/2024 | 383.12 | 299.68 |
|
Prepared for Ray- Orig CA home
Zip code: 95223 Age: 77 |
|
UHC rates based on Part B effective 10 or more years
|