| 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: 412.87 I: Additional benefits included with Anthem Innovative plan rider
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296.37 | 318.86 | |
| Blue Shield | 373.00 | S: 312.00 Extra Rider
E: 328.00 |
283 | |
| Continental (Aetna) | 455.98 | 334.37 | 248.07 | |
| Health Net | S: 341.00 Additional benefits included with Health Net Innovative plan rider
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S: 303.00 Additional benefits included with Health Net Innovative plan rider
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137.00 | 270.00 |
| Humana Achieve | 305.65 | 269.75 | 92.41 | 220.44 |
| ManhattanLife | 334.83 | 269.08 | 227.75 | |
| National Health Ins | 382.68 | 326.37 | 257.58 | |
| Physicians Mutual | 317.07 | 276.78 | 230.10 | |
| United American to 4/30/2024 | 412.00 | 341.00 | 81.00 | 277.00 |
| United American eff 5/1/2024 | 439.00 | 366.00 | 88.00 | 304.00 |
| UHC to 5/31/2024 | 313.75 | 245.25 | 207.75 | |
| UHC eff 6/1/2024 | 350.00 | 273.75 | 231.75 |
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Prepared for
Zip code: 91367 Age: 77 |
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UHC rates based on Part B effective less than 10 years
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