ZapIndex

Part A Hospital Services	G	G-ded	K	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
The inpatient deductible is $1632 for each benefit period Days 1-60: Medicare covers 100% Days 61-90: You are responsible for $408 per day Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day Beyond lifetime reserve: You are responsible for all costs incurred Hospital 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%
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%
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%
Part B Services	G	G-ded	K	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%	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	G	G-ded	K	N
Out of Pocket Limit	NA	NA	$5120	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%
Foreign Travel Emergency
Monthly Rates & Brochures	G	G-ded	K	N
Blue Shield eff 7/1/2024 CKHH	S: 355.00 Extra Rider Basic gym access through sliver sneakers fitness program (silversneakers.com) Personal emergency response system Physician consultation by phone or video through Teladoc Over the counter items through CVS (Up to $100 one time use per quarter allowance) The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance) Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay Acupuncture and chiropractic, up to 20 combined visits per calendar year Identity theft protection E: 372.00			310
Health Net	S: 303.00 Additional benefits included with Health Net Innovative plan rider Vision Benefits Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance Medically necessary contact Lenses - Up to $250 allowance Hearing Benefits Routine Hearing Exam - One hearing exam every 12 months Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions Level 4 - You pay $1580 Level 3 - You pay $1125 Level 2 - You pay $700 Level 1 - You pay $0 See page 44 in Health Net brochure for detailsI: 284.00	125.00		245.00
Choosing a Medigap Policy

Part A Hospital Services

G-ded

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

The inpatient deductible is $1632 for each benefit period
Days 1-60: Medicare covers 100%
Days 61-90: You are responsible for $408 per day
Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day
Beyond lifetime reserve: You are responsible for all costs incurred

Hospital 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%

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%

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%

Part B Services

G-ded

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%

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

G-ded

Out of Pocket Limit

$5120

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%

Foreign Travel Emergency

Monthly Rates & Brochures

G-ded

Blue Shield eff 7/1/2024 CKHH

S: 355.00

Extra Rider

Basic gym access through sliver sneakers fitness program (silversneakers.com)
Personal emergency response system
Physician consultation by phone or video through Teladoc
Over the counter items through CVS (Up to $100 one time use per quarter allowance)
The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance)
Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay
Acupuncture and chiropractic, up to 20 combined visits per calendar year
Identity theft protection

E: 372.00

310

Health Net

S: 303.00
Additional benefits included with Health Net Innovative plan rider

Vision Benefits
Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment
Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance
Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance
Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance
Medically necessary contact Lenses - Up to $250 allowance
Hearing Benefits
Routine Hearing Exam - One hearing exam every 12 months
Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions
- Level 4 - You pay $1580
- Level 3 - You pay $1125
- Level 2 - You pay $700
- Level 1 - You pay $0

See page 44 in Health Net brochure for detailsI: 284.00

125.00

245.00

Choosing a Medigap Policy