| Part A Hospital Services | F | F-ded | 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) |
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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 |
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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 |
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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 |
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| Part B Services | F | F-ded | G | G-ded | 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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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 | N |
| Out of Pocket Limit | NA | 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 |
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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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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 847.64 I: Additional benefits included with Anthem Innovative plan rider
|
608.43 | 654.63 | ||
| Blue Shield | 843.00 | S: 692.00 Extra Rider
E: 723.00 |
588 | ||
| Continental (Aetna) | 964.62 | 180.51 | 706.80 | 502.35 | |
| Health Net | S: 700.00 Additional benefits included with Health Net Innovative plan rider
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303.00 | S: 558.00 Additional benefits included with Health Net Innovative plan rider
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294.00 | 558.00 |
| Humana Achieve | 576.39 | 510.20 | 172.29 | 420.57 | |
| Physicians Mutual | 667.44 | 581.92 | 482.84 | ||
| United American to 4/30/2024 | 862.00 | 176.00 | 714.00 | 176.00 | 583.00 |
| United American eff 5/1/2024 | 918.00 | 192.00 | 767.00 | 192.00 | 640.00 |
| UHC to 5/31/2024 | 729.45 | 570.20 | 483.00 | ||
| UHC eff 6/1/2024 | 813.75 | 636.45 | 538.80 |
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Prepared for KOUJI & MARY NAKATA
Zip code: 91364 Age: 80 Spouse: 78 |
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Anthem rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement for subscribermember may qualify for a household discount
Anthem spouse rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
Humana Achieve rates 12% household discount UHC rates based on Part B effective 10 or more years UHC spousal rates based on Part B effective 10 or more years UHC rates reflect 7% You can take 7% off your monthly premiums if
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