| Part A Hospital Services | F | F-ded | 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) |
 |
$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 |
|
|
|
|
$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 |
|
|
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
|
|
| 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 |
|
|
| 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 |
|
|
| Part B Services | F | F-ded | G | N |
| Part B Annual Deductible ($240) | |
|||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
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 | 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 |
|
|
| Foreign Travel Emergency | |
|
|
|
| Monthly Rates & Brochures | F | F-ded | G | N |
| Anthem | S: 314.76 I: Additional benefits included with Anthem Innovative plan rider
|
225.92 | 243.07 | |
| Blue Shield eff 7/1/2024 | 275.00 | S: 227.00 Extra Rider
E: 242.00 |
211 | |
| Blue Shield to 6/30/2024 | 257.00 | S: 212.00 Extra Rider
E: 226.00 |
197 | |
| Health Net | S: 257.00 Additional benefits included with Health Net Innovative plan rider
|
112.00 | S: 229.00 Additional benefits included with Health Net Innovative plan rider
|
194.00 |
| UHC to 5/31/2024 | 247.86 | 193.75 | 164.12 | |
| UHC eff 6/1/2024 | 276.50 | 216.26 | 183.08 |
|
Prepared for
Zip code: 91364 Age: 70 |
|
UHC rates based on Part B effective less than 10 years
|