| Part A Hospital Services | A | B | D | F | G | G-ded | K | L | M | N |
|---|---|---|---|---|---|---|---|---|---|---|
| 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) |
 |
|
|
|
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
|
|
|
|
|
|
|
|
|
|
|
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
Plan covers 50% Part A deductible50% | |
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
|
|
|
|
|
|
|
|
| Skilled nursing facility coinsurance | |
|
|
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|||
| 3 Pints of (unreplaced) blood | |
|
|
|
|
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|
| Part B Services | A | B | D | F | G | G-ded | K | L | M | N |
| Part B Annual Deductible ($240) | |
|||||||||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
|
|
|
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
You pay $20 for Dr. office visits You pay $50 for emergency room visits$20/$50 |
| 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 | A | B | D | F | G | G-ded | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | NA | $5120 | $2560 | NA | NA |
| Hospice coverage | |
|
|
|
|
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|
| Foreign Travel Emergency | |
|
|
|
|
|
|
|||
| Monthly Rates & Brochures | A | B | D | F | G | G-ded | K | L | M | N |
| Anthem | 278.33 | S: 481.73 I: Additional benefits included with Anthem Innovative plan rider
|
345.78 | 372.03 | ||||||
| Blue Shield eff 7/1/2024 | 248.00 | 509.00 | S: 413.00 Extra Rider
E: 429.00 |
337 | ||||||
| Blue Shield to 6/30/2024 | 248.00 | 469.00 | S: 381.00 Extra Rider
E: 396.00 |
311 | ||||||
| Health Net | 271.00 | 304.00 | S: 387.00 Additional benefits included with Health Net Innovative plan rider
|
S: 345.00 Additional benefits included with Health Net Innovative plan rider
|
133.00 | 263.00 | ||||
| United American to 4/30/2024 | 212.00 | 302.00 | 393.00 | 441.00 | 366.00 | 93.00 | 187.00 | 264.00 | 300.00 | |
| United American eff 5/1/2024 | 217.00 | 309.00 | 413.00 | 470.00 | 393.00 | 102.00 | 187.00 | 264.00 | 329.00 | |
| UHC to 5/31/2024 | 231.87 | 323.75 | 392.18 | 306.56 | 215.31 | 259.68 | ||||
| UHC eff 6/1/2024 | 258.75 | 360.93 | 437.50 | 342.18 | 240.00 | 289.68 |
|
Prepared for Eddie Levin
Zip code: 91201 Age: 81 |
|
UHC rates based on Part B effective 10 or more years
|