Part A Hospital Services G K
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)
  • 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		 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 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
3 Pints of (unreplaced) blood Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
Part B Services G K
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%
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 K
Out of Pocket Limit NA $5120
Hospice coverage Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
Foreign Travel Emergency
Monthly Rates & Brochures G K
Health Net
S: 229.00
Additional benefits included with Health Net Innovative plan rider
  • Routine Hearing Exam - One hearing exam every 12 months
  • Hearing Aid(s) - includes fitting evaluation. $1000 maximum for two hearing aids (one pair) or $500 for one hearing aid
  • Routine Eye Exam - One vision exam every 12 months
  • Eyewear - Up to $250 allowance for frame and lens package once every 24 months or contact lens once every 12 months
I: 227.00
UHC 191.75
Prepared for DENISE O DONNEL
Zip code: 92653
Age: 70

UHC rates based on Part B effective less than 10 years
UHC rates reflect $2 automatic checking discount