| Part A Hospital Services | F | F-ded | 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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$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: 629.91 I: Additional benefits included with Anthem Innovative plan rider
|
452.17 | 486.50 | ||
| Blue Shield eff 7/1/2024 | 513.36 | S: 420.36 Extra Rider
E: 451.98 |
391.53 | ||
| Blue Shield to 6/30/2024 | 479.88 | S: 392.46 Extra Rider
E: 422.22 |
365.49 | ||
| Continental (Aetna) | 711.64 | 132.95 | 521.37 | 358.71 | |
| Health Net | S: 535.00 Additional benefits included with Health Net Innovative plan rider
|
231.00 | S: 424.00 Additional benefits included with Health Net Innovative plan rider
|
217.00 | 407.00 |
| Humana Achieve | 485.33 | 419.35 | 147.84 | 331.24 | |
| Physicians Mutual | 508.56 | 443.53 | 368.17 | ||
| United American to 4/30/2024 | 682.00 | 121.00 | 557.00 | 121.00 | 448.00 |
| United American eff 5/1/2024 | 726.00 | 133.00 | 598.00 | 133.00 | 492.00 |
| UHC to 5/31/2024 | 451.80 | 353.16 | 299.16 | ||
| UHC eff 6/1/2024 | 504.00 | 394.20 | 333.72 |
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Prepared for LUCIE & NECHEMIA VOLOZKY
Zip code: 91303 Age: 69 Spouse: 71 |
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Blue Shield rates reflect 7% You are eligible for a 7% household premium discount if you reside with another person
who is on the same Blue Shield Medicare Supplement plan, including same Dental plan. Only one policy will be issued, the second party will be covered as a dependent.household discount 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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