| 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) |
 |
|
$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 |
|
|
|
|
$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 | F | 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 | F | G | G-ded | N |
| Out of Pocket Limit | 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 |
|
| Foreign Travel Emergency | |
|
|
|
| Monthly Rates & Brochures | F | G | G-ded | N |
| Anthem | S: 481.73 I: Additional benefits included with Anthem Innovative plan rider
|
345.78 | 372.03 | |
| Blue Shield | 511.00 | S: 430.00 Extra Rider
E: 446.00 |
341 | |
| Continental (Aetna) | 520.13 | 381.01 | 286.89 | |
| Health Net | S: 434.00 Additional benefits included with Health Net Innovative plan rider
|
S: 387.00 Additional benefits included with Health Net Innovative plan rider
|
164.00 | 324.00 |
| Humana Achieve | 396.59 | 353.25 | 115.16 | 296.60 |
| ManhattanLife | 452.33 | 373.00 | 323.00 | |
| National Health Ins | 472.35 | 402.47 | 318.00 | |
| Physicians Mutual | 388.80 | 339.23 | 281.86 | |
| United American to 4/30/2024 | 441.00 | 366.00 | 93.00 | 300.00 |
| United American eff 5/1/2024 | 470.00 | 393.00 | 102.00 | 329.00 |
| UHC to 5/31/2024 | 313.75 | 245.25 | 207.75 | |
| UHC eff 6/1/2024 | 350.00 | 273.75 | 231.75 |
|
Prepared for
Zip code: 91325 Age: 84 |
|
UHC rates based on Part B effective less than 10 years
|