| 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) |
 |
|
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
|
|
|
|
|
|
|
|
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | |
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | |
|
|
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | |
|
|
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | 181.84 | S: 314.76 I: Additional benefits included with Anthem Innovative plan rider
|
225.92 | 243.07 | ||||||
| Blue Shield eff 7/1/2024 | 156.00 | 275.00 | S: 227.00 Extra Rider
E: 242.00 |
211 | ||||||
| Blue Shield to 6/30/2024 | 156.00 | 257.00 | S: 212.00 Extra Rider
E: 226.00 |
197 | ||||||
| United American to 4/30/2024 | 185.00 | 253.00 | 300.00 | 342.00 | 279.00 | 61.00 | 163.00 | 231.00 | 225.00 | |
| United American eff 5/1/2024 | 190.00 | 260.00 | 315.00 | 364.00 | 300.00 | 67.00 | 163.00 | 231.00 | 247.00 | |
| UHC to 5/31/2024 | 146.55 | 204.61 | 247.86 | 193.75 | 136.08 | 164.12 | ||||
| UHC eff 6/1/2024 | 163.53 | 228.11 | 276.50 | 216.26 | 151.68 | 183.08 |
|
Prepared for Elaine Antonio
Zip code: 90066 Age: 70 |
|
UHC rates based on Part B effective less than 10 years
|