| Part A Hospital Services | F | F-ded | G | G-ded | K | 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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$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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$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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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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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$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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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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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$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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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| Part B Services | F | F-ded | G | G-ded | K | 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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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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 | G-ded | K | N |
| Out of Pocket Limit | NA | NA | NA | NA | $5120 | 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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$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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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| Foreign Travel Emergency | |
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| Monthly Rates | F | F-ded | G | G-ded | K | N |
| Anthem | S: 661.99 I: Additional benefits included with Anthem Innovative plan rider
|
475.18 | 511.25 | |||
| Blue Shield | 565.44 | S: 476.16 Extra Rider
E: 502.20 |
444.54 | |||
| Continental (Aetna) | 829.66 | 155.10 | 607.76 | 424.16 | ||
| Health Net | S: 598.00 Additional benefits included with Health Net Innovative plan rider
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258.00 | S: 476.00 Additional benefits included with Health Net Innovative plan rider
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247.00 | 464.00 | |
| Humana Achieve | 477.61 | 417.93 | 147.40 | 335.97 | ||
| Physicians Mutual | 576.18 | 502.46 | 417.00 | |||
| United American | 774.00 | 148.00 | 638.00 | 148.00 | 352.00 | 516.00 |
| UHC | 527.10 | 412.02 | 349.02 |
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Prepared for THOMAS ZIMMER
Zip code: 91356 Age: 74 Spouse: 74 |
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Anthem rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for subscriber
Anthem spouse rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
Blue Shield rates reflect 7% You are eligible for a 7% household premium discount if you reside with another person
who is on the same Blue Shield Medicare Supplement plan, including same Dental plan. Only one policy will be issued, the second party will be covered as a dependent.household discount Humana Achieve rates 12% household discount UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years UHC rates reflect 7% You can take 7% off your monthly premiums if
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