| Part A Hospital Services | F | F-ded | G | G-ded | N |
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| 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: 349.19 I: Additional benefits included with Anthem Innovative plan rider
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247.38 | 260.94 | ||
| Blue Shield | 346.00 | S: 291.00 Extra Rider
E: 306.00 |
280 | ||
| Continental (Aetna) | 353.44 | 66.06 | 259.06 | 190.67 | |
| Health Net | S: 314.00 Additional benefits included with Health Net Innovative plan rider
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136.00 | S: 279.00 Additional benefits included with Health Net Innovative plan rider
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120.00 | 236.00 |
| Humana Achieve | 237.87 | 208.76 | 73.75 | 168.70 | |
| Physicians Mutual | 265.21 | 231.64 | 192.69 | ||
| United American to 4/30/2024 | 298.00 | 59.00 | 245.00 | 59.00 | 199.00 |
| United American eff 5/1/2024 | 317.00 | 64.00 | 264.00 | 64.00 | 218.00 |
| UHC to 5/31/2024 | 387.40 | 302.83 | 256.61 | ||
| UHC eff 6/1/2024 | 441.75 | 345.55 | 292.65 |
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Prepared for
Zip code: 92211 Age: 75 |
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UHC 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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