Part A Hospital Services A B C 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
  • 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		 $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 C 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 C G G-ded K L M N
Out of Pocket Limit 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 C G G-ded K L M N
Anthem 189.09

234.93



252.76
Blue Shield 167.00

S: 230.00
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: 246.00



209
Continental (Aetna) 208.25 263.73
270.64



196.50
Health Net 195.00

S: 247.00
Additional benefits included with Health Net Innovative plan rider
  • Routine Hearing Exam - One hearing exam every 12 months
  • Hearing Aid(s) - includes fitting evaluation. $1000 maximum for two hearing aids (one pair) or $500 for one hearing aid
  • Routine Eye Exam - One vision exam every 12 months
  • Eyewear - Up to $250 allowance for frame and lens package once every 24 months or contact lens once every 12 months
I: 247.00
 108.00


213.00
Humana Achieve 203.43

215.21 76.16


170.07
ManhattanLife 210.83

211.92



179.67
National Health Ins 235.85

263.09



207.74
Physicians Mutual 213.67

232.07



193.05
United American to 4/30/2024 192.00 263.00 348.00 292.00 63.00 168.00 237.00
235.00
United American eff 5/1/2024 197.00 269.00 365.00 313.00 69.00 168.00 237.00
258.00
UHC to 5/31/2024 152.11 212.38 256.05 201.11

141.25
170.36
UHC eff 6/1/2024 169.74 236.78 285.57 224.48

157.44
190.04

Prepared for
Zip code: 92804
Age: 71
Select all that apply
  • Anthem $2 per month
  • Blue Shield $3 per month
  • Humana Achieve $2 per month
  • Physicians Mutual $5 per month
  • United Healthcare $2 per month
Automatic Checking Withdrawal Discount
If you are new to Medicare the following monthly discounts
are available for your first year of coverage
  • Anthem Plan F: $20 Plans G: $25 per month
  • Blue Shield Plans A. F and G: $25 per month
  • Health Net All Plans: $30 per month
  • United Healthcare Plan G: $25 per month
Welcome to Medicare discount 2 party
Enrollees who live with another Anthem Medicare Supplement
member may qualify for a household discount.
  • For members with an original Anthem Blue Cross
    effective date after 2/28/2023 the discount is 10%
  • For those with original effective dates between
    6/1/2010 and 2/28/2023 the discount is 5%
  • The household discount is not available to persons
    enrolled before 6/1/2010
Anthem household discount
Blue ShieldYou are eligible for a 7% household premium discount
  • if you reside with another person who is on the same Blue Shield Medicare Supplement plan
  • including same Dental plan.
Only one policy will be issued, the second party will be covered as a dependent. household discount (7%)
Humana AchieveHumana Achieve offers a 12% household premium discount
  • if you reside with your spouse or domestic partner
  • or if you have resided with one to three adults for the past 12 months.
 household discount (12%)
ManhattanLifeManhattanLife offers a 7% household premium discount
  • if you are marriied and residing with your spouse
  • or have been residing, for at the past 12 months, with someone who is 60 or over
 household discount (7%)
National Health Insurance National Health Insurance
  • You are eligible for a 7% household premium discount if you have a roommate
  • You are eligible for a 10% discount if multiple people in your household are
    covered by National Health Ins. medicare supplement policies
household discount
Physicians Mutual 10% Physicians Mutual offers a 10% household premium discount
if you are marriied
or reside with another person age 60 or over.household discount
UHC/AARPYou can take 7% off your monthly premiums if
  • two or more members are enrolled under the same AARP membership number
  • and each is insured under an eligible AARP-branded supplemental insurance
    policy insured by UnitedHealthcare Insurance Company.
 household discount (7%)
Contact us
(530) 345-1162
[email protected]
CA Ins Lic 0687178