| Part A Hospital Services | A | B | C | D | F | F-ded | 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 |
|
$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 |
|
|
|
|
|
|
|
|
|
|
|
$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 |
|
$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 |
|
$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 |
|
$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 | D | F | F-ded | 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 | D | F | F-ded | G | G-ded | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | 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 |
|
$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 | D | F | F-ded | G | G-ded | K | L | M | N |
| Anthem | 141.09 | S: 236.01 I: Additional benefits included with Anthem Innovative plan rider
|
167.21 | 176.38 | ||||||||
| Blue Shield | 119.00 | 197.00 | S: 146.00 Extra Rider
E: 163.00 |
143 | ||||||||
| Continental (Aetna) | 165.52 | 209.42 | 293.63 | 54.89 | 215.16 | 154.35 | ||||||
| Health Net | 133.00 | 156.00 | S: 190.00 Additional benefits included with Health Net Innovative plan rider
|
82.00 | S: 170.00 Additional benefits included with Health Net Innovative plan rider
|
68.00 | 135.00 | |||||
| Humana Achieve | 159.03 | 194.55 | 168.83 | 57.09 | 132.14 | |||||||
| ManhattanLife | 150.25 | 186.08 | 151.08 | 128.33 | ||||||||
| National Health Ins | 174.78 | 228.56 | 67.01 | 194.94 | 154.04 | |||||||
| Physicians Mutual | 170.30 | 211.54 | 184.86 | 153.97 | ||||||||
| United American to 4/30/2024 | 110.00 | 148.00 | 195.00 | 172.00 | 200.00 | 34.00 | 160.00 | 34.00 | 93.00 | 131.00 | 128.00 | |
| United American eff 5/1/2024 | 113.00 | 152.00 | 205.00 | 180.00 | 213.00 | 37.00 | 172.00 | 37.00 | 93.00 | 131.00 | 141.00 | |
| UHC to 5/31/2024 | 115.04 | 160.48 | 193.60 | 194.56 | 152.00 | 106.88 | 128.80 | |||||
| UHC eff 6/1/2024 | 128.32 | 179.04 | 216.00 | 216.96 | 169.60 | 119.04 | 143.68 |
|
Prepared for
Zip code: 92131 Age: 65 |
|
UHC rates based on Part B effective less than 10 years
|