Part A Hospital Services G G-ded 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
  • The inpatient deductible is $1632 for each benefit period
  • Days 1-60: Medicare covers 100%
  • Days 61-90: You are responsible for $408 per day
  • Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day
  • Beyond lifetime reserve: You are responsible for all costs incurred
Hospital 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
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 G G-ded 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 G G-ded N
Out of Pocket Limit 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 G G-ded N
Anthem 219.24
262.78
Blue Shield
S: 213.00
Extra Rider
  • Basic gym access through sliver sneakers fitness program (silversneakers.com)
  • Personal emergency response system
  • Physician consultation by phone or video through Teladoc
  • Over the counter items through CVS (Up to $100 one time use per quarter allowance)
  • The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance)
  • Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay
  • Acupuncture and chiropractic, up to 20 combined visits per calendar year
  • Identity theft protection
E: 228.00
223
Continental (Aetna) 315.79
230.32
Health Net
S: 217.00
Additional benefits included with Health Net Innovative plan rider
  • Routine Hearing Exam - One hearing exam every 12 months
  • Hearing Aid(s) - includes fitting evaluation. $1000 maximum for two hearing aids (one pair) or $500 for one hearing aid
  • Routine Eye Exam - One vision exam every 12 months
  • Eyewear - Up to $250 allowance for frame and lens package once every 24 months or contact lens once every 12 months
I: 217.00
 78.00 183.00
Humana Achieve 195.91 69.25 155.77
United American to 4/30/2024 225.00 50.00 182.00
United American eff 5/1/2024 242.00 55.00 200.00
UHC to 5/31/2024 183.46
176.59
UHC eff 6/1/2024 207.69
196.99
Prepared for Stephen Schmones
Zip code: 91604
Age: 72

Anthem Plan G rates reflect $25.00 Welcome to Medicare discount
Blue Shield Plan G rates reflect $25 Welcome to Medicare discount
Health Net rates reflect $30 Welcome to Medicare discount
Humana Achieve rates 12% household discount
UHC rates based on Part B effective less than 10 years
UHC Plan G rates reflect $25 Welcome to Medicare discount
Contact us
(818) 888-0880
[email protected]
CA Ins Lic OA2225