| 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) |
 |
$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 |
|
|
|
|
$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 |
|
|
| 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 |
|
|
| 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 |
|
|
| 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 | |
$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 |
|
|
| Foreign Travel Emergency | |
|
|
|
| Monthly Rates & Brochures | F | F-ded | G | N |
| Anthem | S: 481.73 I: Additional benefits included with Anthem Innovative plan rider
|
345.78 | 372.03 | |
| Blue Shield eff 7/1/2024 | 593.00 | S: 497.00 Extra Rider
E: 514.00 |
394 | |
| Blue Shield to 6/30/2024 | 547.00 | S: 458.00 Extra Rider
E: 474.00 |
363 | |
| Continental (Aetna) | 657.90 | 123.12 | 482.14 | 365.77 |
| Health Net | S: 434.00 Additional benefits included with Health Net Innovative plan rider
|
188.00 | S: 387.00 Additional benefits included with Health Net Innovative plan rider
|
401.00 |
| Humana Achieve to 7/31/2024 | 536.39 | 480.73 | 412.96 | |
| Humana Achieve eff 8/1/2024 | 576.48 | 516.64 | 412.96 | |
| ManhattanLife | 687.25 | 583.08 | 509.00 | |
| National Health Ins | 606.48 | 177.89 | 517.04 | 408.32 |
| Physicians Mutual | 400.32 | 349.28 | 290.16 | |
| United American to 4/30/2024 | 441.00 | 93.00 | 366.00 | 300.00 |
| United American eff 5/1/2024 | 470.00 | 102.00 | 393.00 | 329.00 |
| UHC to 5/31/2024 | 392.18 | 306.56 | 259.68 | |
| UHC eff 6/1/2024 | 437.50 | 342.18 | 289.68 |
|
Prepared for
Zip code: 92603 Age: 94 |
|
UHC rates based on Part B effective 10 or more years
|