| 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: 397.32 I: Additional benefits included with Anthem Innovative plan rider
|
285.18 | 306.84 | ||
| Blue Shield eff 7/1/2024 | 380.00 | S: 318.00 Extra Rider
E: 335.00 |
292 | ||
| Blue Shield to 6/30/2024 | 353.00 | S: 296.00 Extra Rider
E: 312.00 |
272 | ||
| Continental (Aetna) | 497.88 | 93.13 | 364.94 | 269.64 | |
| Health Net | S: 320.00 Additional benefits included with Health Net Innovative plan rider
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138.00 | S: 286.00 Additional benefits included with Health Net Innovative plan rider
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114.00 | 227.00 |
| Humana Achieve | 295.72 | 260.59 | 89.89 | 211.97 | |
| Physicians Mutual | 307.98 | 268.87 | 223.56 | ||
| United American to 4/30/2024 | 404.00 | 79.00 | 334.00 | 79.00 | 271.00 |
| United American eff 5/1/2024 | 431.00 | 87.00 | 359.00 | 87.00 | 297.00 |
| UHC to 5/31/2024 | 304.34 | 237.89 | 201.52 | ||
| UHC eff 6/1/2024 | 339.50 | 265.54 | 224.80 |
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Prepared for
Zip code: 90266 Age: 76 |
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UHC rates based on Part B effective less than 10 years
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