| Part A Hospital Services | F | F-ded | G | 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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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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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 | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| 3 Pints of (unreplaced) blood | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| Part B Services | F | F-ded | 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 | F-ded | G | N |
| Out of Pocket Limit | NA | NA | NA | NA |
| Hospice coverage | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | N |
| Anthem | S: 481.73 I: Additional benefits included with Anthem Innovative plan rider
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345.78 | 372.03 | |
| Blue Shield eff 7/1/2024 | 535.00 | S: 441.00 Extra Rider
E: 458.00 |
357 | |
| Blue Shield to 6/30/2024 | 493.00 | S: 407.00 Extra Rider
E: 422.00 |
329 | |
| Health Net | S: 387.00 Additional benefits included with Health Net Innovative plan rider
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167.00 | S: 345.00 Additional benefits included with Health Net Innovative plan rider
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306.00 |
| UHC to 5/31/2024 | 313.75 | 245.25 | 207.75 | |
| UHC eff 6/1/2024 | 350.00 | 273.75 | 231.75 |
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Prepared for
Zip code: 92653 Age: 82 |
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UHC rates based on Part B effective less than 10 years
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