| 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: 765.09 I: Additional benefits included with Anthem Innovative plan rider
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549.17 | 590.87 | ||
| Blue Shield to 6/30/2024 | 657.00 | S: 552.00 Extra Rider
E: 582.00 |
511 | ||
| Continental (Aetna) | 858.24 | 160.52 | 628.92 | 440.22 | |
| Health Net | S: 619.00 Additional benefits included with Health Net Innovative plan rider
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267.00 | S: 492.00 Additional benefits included with Health Net Innovative plan rider
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256.00 | 482.00 |
| Humana Achieve | 567.09 | 498.05 | 173.64 | 402.86 | |
| Physicians Mutual | 593.57 | 517.60 | 429.56 | ||
| United American to 4/30/2024 | 791.00 | 153.00 | 653.00 | 153.00 | 529.00 |
| United American eff 5/1/2024 | 843.00 | 168.00 | 702.00 | 168.00 | 581.00 |
| UHC to 5/31/2024 | 545.93 | 426.74 | 361.49 | ||
| UHC eff 6/1/2024 | 609.00 | 476.33 | 403.25 |
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Prepared for CLAIRE KOSASKY & MELVIN
Zip code: 91325 Age: 74 Spouse: 76 |
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UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years UHC rates reflect 7% You can take 7% off your monthly premiums if
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