| Part A Hospital Services | A | B | D | F | G | G-ded | K | L | M | N |
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| 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) |
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$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 |
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$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 | |
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| Skilled nursing facility coinsurance | |
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$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% |
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| 3 Pints of (unreplaced) blood | |
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$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% |
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| Part B Services | A | B | D | F | G | G-ded | K | L | M | N |
| Part B Annual Deductible ($240) | |
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| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
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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% |
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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 |
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| 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 | |
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$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% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | D | F | G | G-ded | K | L | M | N |
| Anthem | 189.09 | S: 327.28 I: Additional benefits included with Anthem Innovative plan rider
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234.93 | 252.76 | ||||||
| Blue Shield eff 7/1/2024 | 167.00 | 286.00 | S: 239.00 Extra Rider
E: 256.00 |
223 | ||||||
| Blue Shield to 6/30/2024 | 167.00 | 269.00 | S: 224.00 Extra Rider
E: 240.00 |
209 | ||||||
| United American to 4/30/2024 | 192.00 | 263.00 | 313.00 | 356.00 | 292.00 | 63.00 | 168.00 | 237.00 | 235.00 | |
| United American eff 5/1/2024 | 197.00 | 269.00 | 329.00 | 379.00 | 313.00 | 69.00 | 168.00 | 237.00 | 258.00 | |
| UHC to 5/31/2024 | 152.11 | 212.38 | 257.28 | 201.11 | 141.25 | 170.36 | ||||
| UHC eff 6/1/2024 | 169.74 | 236.78 | 287.00 | 224.48 | 157.44 | 190.04 |
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Prepared for Elaine Antonio
Zip code: 90066 Age: 71 |
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UHC rates based on Part B effective less than 10 years
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