| Part A Hospital Services | F | G | 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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| 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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| 3 Pints of (unreplaced) blood | |
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| Part B Services | F | G | 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 | G | N |
| Out of Pocket Limit | NA | NA | NA |
| Hospice coverage | |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | G | N |
| Anthem | S: 879.05 I: Additional benefits included with Anthem Innovative plan rider
|
630.96 | 678.87 |
| Blue Shield | 833.00 | S: 692.00 Extra Rider
E: 725.00 |
590 |
| UHC to 5/31/2024 | 618.09 | 483.14 | 409.27 |
| UHC eff 6/1/2024 | 689.50 | 539.29 | 456.55 |
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Prepared for
Zip code: 90275 Age: 82 Spouse: 76 |
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UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years
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