| Part A Hospital Services | F | G | L | 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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Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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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 | |
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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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Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| Part B Services | F | G | L | 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 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 |
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| Additional Features | F | G | L | N |
| Out of Pocket Limit | NA | NA | $2560 | NA |
| Hospice coverage | |
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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 | F | G | L | N |
| Anthem | S: 298.97 I: Additional benefits included with Anthem Innovative plan rider
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211.81 | 223.41 | |
| Health Net | S: 272.00 Additional benefits included with Health Net Innovative plan rider
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S: 243.00 Additional benefits included with Health Net Innovative plan rider
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202.00 | |
| UHC to 5/31/2024 | 273.27 | 213.61 | 150.06 | 181.02 |
| UHC eff 6/1/2024 | 311.60 | 243.75 | 170.97 | 206.44 |
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Prepared for
Zip code: 93035 Age: 71 |
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UHC rates based on Part B effective less than 10 years
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