| Part A Hospital Services | F | F-ded | 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) |
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$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 |
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$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 |
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$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 |
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$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 |
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| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
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| 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 |
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$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 |
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| 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 |
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$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 |
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| Part B Services | F | F-ded | G | G-ded | 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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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 | F | F-ded | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | 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 |
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$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 |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 314.76 I: Additional benefits included with Anthem Innovative plan rider
|
225.92 | 243.07 | ||
| Blue Shield to 6/30/2024 | 265.00 | S: 218.00 Extra Rider
E: 233.00 |
197 | ||
| Continental (Aetna) | 355.19 | 66.56 | 260.40 | 188.51 | |
| Health Net | S: 257.00 Additional benefits included with Health Net Innovative plan rider
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112.00 | S: 229.00 Additional benefits included with Health Net Innovative plan rider
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98.00 | 194.00 |
| Humana Achieve | 240.46 | 207.79 | 73.65 | 163.14 | |
| ManhattanLife | 250.25 | 203.83 | 172.42 | ||
| National Health Ins | 296.66 | 86.85 | 252.99 | 199.80 | |
| Physicians Mutual | 256.93 | 224.37 | 186.71 | ||
| United American to 4/30/2024 | 342.00 | 61.00 | 279.00 | 61.00 | 225.00 |
| United American eff 5/1/2024 | 364.00 | 67.00 | 300.00 | 67.00 | 247.00 |
| UHC to 5/31/2024 | 247.86 | 193.75 | 164.12 |
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Prepared for
Zip code: 92804 Age: 70 |
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UHC rates based on Part B effective less than 10 years
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