| 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: 408.94 I: Additional benefits included with Anthem Innovative plan rider
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297.61 | 307.89 | ||
| Blue Shield eff 7/1/2024 | 459.00 | S: 385.00 Extra Rider
E: 401.00 |
322 | ||
| Blue Shield to 6/30/2024 | 423.00 | S: 355.00 Extra Rider
E: 370.00 |
297 | ||
| Health Net | S: 395.00 Additional benefits included with Health Net Innovative plan rider
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171.00 | S: 352.00 Additional benefits included with Health Net Innovative plan rider
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149.00 | 294.00 |
| Humana Achieve | 380.89 | 338.87 | 111.28 | 283.57 | |
| Physicians Mutual | 305.96 | 267.11 | 222.11 | ||
| United American to 4/30/2024 | 386.00 | 81.00 | 320.00 | 81.00 | 262.00 |
| United American eff 5/1/2024 | 411.00 | 89.00 | 344.00 | 89.00 | 288.00 |
| UHC to 5/31/2024 | 343.12 | 268.12 | 227.18 | ||
| UHC eff 6/1/2024 | 383.12 | 299.68 | 253.75 |
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Prepared for DAVID TEGNELL
Zip code: 96002 Age: 83 |
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UHC rates based on Part B effective 10 or more years
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