ZapIndex

Part A Hospital Services	G	G-ded	K	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)		$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
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		$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%
Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage
Skilled nursing facility coinsurance		$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%
3 Pints of (unreplaced) blood		$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%
Part B Services	G	G-ded	K	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%	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	G	G-ded	K	N
Out of Pocket Limit	NA	NA	$5120	NA
Hospice coverage		$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%
Foreign Travel Emergency
Monthly Rates & Brochures	G	G-ded	K	N
Cigna HH	194.39			138.36
Health Net	S: 191.00 Additional benefits included with Health Net Innovative plan rider Vision Benefits Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance Medically necessary contact Lenses - Up to $250 allowance Hearing Benefits Routine Hearing Exam - One hearing exam every 12 months Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions Level 4 - You pay $1580 Level 3 - You pay $1125 Level 2 - You pay $700 Level 1 - You pay $0 See page 44 in Health Net brochure for detailsI: 186.00	81.00		158.00
Humana Achieve CKHH	215.83	67.68		157.16
UHC CKHH	175.20			148.32
Choosing a Medigap Policy

Part A Hospital Services

G-ded

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)

$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

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

$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%

Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage

Skilled nursing facility coinsurance

$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%

3 Pints of (unreplaced) blood

$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%

Part B Services

G-ded

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%

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

G-ded

Out of Pocket Limit

$5120

Hospice coverage

$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%

Foreign Travel Emergency

Monthly Rates & Brochures

G-ded

Cigna HH

194.39

138.36

Health Net

S: 191.00
Additional benefits included with Health Net Innovative plan rider

Vision Benefits
Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment
Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance
Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance
Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance
Medically necessary contact Lenses - Up to $250 allowance
Hearing Benefits
Routine Hearing Exam - One hearing exam every 12 months
Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions
- Level 4 - You pay $1580
- Level 3 - You pay $1125
- Level 2 - You pay $700
- Level 1 - You pay $0

See page 44 in Health Net brochure for detailsI: 186.00

81.00

158.00

Humana Achieve CKHH

215.83

67.68

157.16

UHC CKHH

175.20

148.32

Choosing a Medigap Policy

Select all that apply

Humana Achieve $2 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

Health Net All Plans: $30 per month
United Healthcare Plan G: $25 per month

Welcome to Medicare discount 2 party

Anthem rates reflect $2 automatic checking discount.

Blue Shield rates reflect $3 automatic checking discount.

Cigna Cigna

You are eligible for a 6% household you live with another person age 18 or over
You are eligible for a 11% discount if another person in your household has a Cigna Medicare Supplement plan

household discount

Health Net rates reflect $30 Welcome to Medicare discount.

Health Net rates reflect $60 2 party Welcome to Medicare discount.

Humana Achieve rates reflect $2 automatic checking discount.

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%)

Physicians Mutual rates reflect $5 automatic checking discount.

UHC Plan G rates reflect $25 Welcome to Medicare discount.

UHC Plan G rates reflect $50 2 party Welcome to Medicare discount.

United Healthcare rates reflect $2 automatic checking 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%)