| Part A Hospital Services | F | G | G-ded | 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 |
|
| 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 |
|
| 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 |
|
| Part B Services | F | G | G-ded | N |
| Part B Annual Deductible ($240) | |
|||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
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 | F | G | G-ded | N |
| Out of Pocket Limit | NA | NA | 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 |
|
| Foreign Travel Emergency | |
|
|
|
| Monthly Rates & Brochures | F | G | G-ded | N |
| Anthem | S: 258.36 I: Additional benefits included with Anthem Innovative plan rider
|
185.46 | 199.55 | |
| Blue Shield eff 7/1/2024 | 227.00 | S: 171.00 Extra Rider
E: 188.00 |
168 | |
| Blue Shield to 6/30/2024 | 210.00 | S: 158.00 Extra Rider
E: 174.00 |
155 | |
| Continental (Aetna) | 329.70 | 241.57 | 173.35 | |
| Health Net | S: 214.00 Additional benefits included with Health Net Innovative plan rider
|
S: 191.00 Additional benefits included with Health Net Innovative plan rider
|
72.00 | 144.00 |
| Physicians Mutual | 238.49 | 208.32 | 173.40 | |
| UHC to 5/31/2024 | 200.80 | 156.96 | 132.96 | |
| UHC eff 6/1/2024 | 224.00 | 175.20 | 148.32 |
|
Prepared for Colleen
Zip code: 90803 Age: 65 |
|
UHC rates based on Part B effective less than 10 years
|