| Part A Hospital Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
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| 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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$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 |
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$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 |
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$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 |
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$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% |
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 | |
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| Skilled nursing facility coinsurance | |
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$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 |
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$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% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| 3 Pints of (unreplaced) blood | |
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$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 |
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$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% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| Part B Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | 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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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% |
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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 | 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 | |
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$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 |
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$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% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Anthem | 171.86 | S: 287.53 I: Additional benefits included with Anthem Innovative plan rider
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203.69 | 214.85 | ||||||||
| Blue Shield eff 7/1/2024 | 171.00 | 290.00 | S: 238.00 Extra Rider
E: 256.00 |
227 | ||||||||
| Blue Shield to 6/30/2024 | 171.00 | 271.00 | S: 223.00 Extra Rider
E: 239.00 |
212 | ||||||||
| Continental (Aetna) | 164.35 | 207.83 | 291.13 | 54.56 | 213.41 | 154.52 | ||||||
| Health Net | 177.00 | 213.00 | S: 253.00 Additional benefits included with Health Net Innovative plan rider
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109.00 | S: 225.00 Additional benefits included with Health Net Innovative plan rider
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93.00 | 184.00 | |||||
| Humana Achieve to 7/31/2024 | 165.98 | 202.00 | 174.60 | 62.09 | 137.15 | |||||||
| Humana Achieve eff 8/1/2024 | 178.28 | 217.00 | 187.55 | 62.09 | 137.15 | |||||||
| ManhattanLife | 170.58 | 210.50 | 171.42 | 145.08 | ||||||||
| National Health Ins | 226.71 | 296.66 | 86.85 | 252.99 | 199.80 | |||||||
| Physicians Mutual | 167.85 | 208.48 | 182.19 | 151.77 | ||||||||
| United American to 4/30/2024 | 139.00 | 190.00 | 251.00 | 225.00 | 257.00 | 46.00 | 210.00 | 46.00 | 123.00 | 173.00 | 169.00 | |
| United American eff 5/1/2024 | 143.00 | 195.00 | 264.00 | 236.00 | 273.00 | 50.00 | 225.00 | 50.00 | 123.00 | 173.00 | 186.00 | |
| UHC to 5/31/2024 | 155.63 | 217.45 | 262.08 | 263.27 | 205.80 | 144.57 | 174.39 | |||||
| UHC eff 6/1/2024 | 177.55 | 247.67 | 298.82 | 300.20 | 234.83 | 164.72 | 198.88 |
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Prepared for
Zip code: 93065 Age: 70 |
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UHC rates based on Part B effective less than 10 years
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