| Part A Hospital Services | F | 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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| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
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| Skilled nursing facility coinsurance | |
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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 | |
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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 | 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 | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | NA |
| Hospice coverage | |
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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 | G | G-ded | N |
| Anthem | S: 277.83 I: Additional benefits included with Anthem Innovative plan rider
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202.2 | 209.18 | |
| Blue Shield | 230.00 | S: 193.00 Extra Rider
E: 209.00 |
189 | |
| Continental (Aetna) | 287.63 | 210.75 | 153.02 | |
| Health Net | S: 227.00 Additional benefits included with Health Net Innovative plan rider
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S: 202.00 Additional benefits included with Health Net Innovative plan rider
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85.00 | 168.00 |
| Humana Achieve | 188.63 | 163.62 | 58.22 | 129.41 |
| ManhattanLife | 196.25 | 159.75 | 135.42 | |
| National Health Ins | 236.56 | 201.70 | 159.26 | |
| United American to 4/30/2024 | 311.00 | 255.00 | 55.00 | 206.00 |
| United American eff 5/1/2024 | 331.00 | 274.00 | 61.00 | 226.00 |
| UHC to 5/31/2024 | 225.09 | 175.89 | 149.04 | |
| UHC eff 6/1/2024 | 251.33 | 196.60 | 166.46 |
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Prepared for
Zip code: 95062 Age: 71 |
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UHC rates based on Part B effective less than 10 years
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