| Part A Hospital Services | C | 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) |
 |
|
|
|
|
|
|
|
|
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
|
|
| Skilled nursing facility coinsurance | |
|
|
|
| 3 Pints of (unreplaced) blood | |
|
|
|
| Part B Services | C | F | 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 | C | F | G | N |
| Out of Pocket Limit | NA | NA | NA | NA |
| Hospice coverage | |
|
|
|
| Foreign Travel Emergency | |
|
|
|
| Monthly Rates & Brochures | C | F | G | N |
| Anthem | S: 258.36 I: Additional benefits included with Anthem Innovative plan rider
|
185.46 | 199.55 | |
| UHC eff 6/1/2024 | 222.88 | 224.00 | 175.20 | 148.32 |
| Choosing a Medigap Policy | ||||
|
Prepared for
Zip code: 91356 Age: 65 |
|
UHC rates based on Part B effective less than 10 years
|