| 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) |
 |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
|
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
|
|
|
| Skilled nursing facility coinsurance | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
| 3 Pints of (unreplaced) blood | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
| Part B Services | F | F-ded | G | G-ded | N |
| Part B Annual Deductible ($240) | |
||||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
|
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 |
|
|
|
|
|
| Additional Features | F | F-ded | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA |
| Hospice coverage | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
|
| Foreign Travel Emergency | |
|
|
|
|
| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 377.15 I: Additional benefits included with Anthem Innovative plan rider
|
267.21 | 281.84 | ||
| Blue Shield eff 7/1/2024 | 429.00 | S: 359.00 Extra Rider
E: 376.00 |
331 | ||
| Blue Shield to 6/30/2024 | 393.00 | S: 329.00 Extra Rider
E: 344.00 |
303 | ||
| Health Net | S: 334.00 Additional benefits included with Health Net Innovative plan rider
|
144.00 | S: 298.00 Additional benefits included with Health Net Innovative plan rider
|
129.00 | 256.00 |
| Humana Achieve to 7/31/2024 | 256.68 | 226.57 | 77.83 | 185.21 | |
| Humana Achieve eff 8/1/2024 | 275.77 | 243.42 | 77.83 | 185.21 | |
| Physicians Mutual | 317.07 | 276.78 | 230.10 | ||
| United American to 4/30/2024 | 412.00 | 81.00 | 341.00 | 81.00 | 277.00 |
| United American eff 5/1/2024 | 439.00 | 88.00 | 366.00 | 88.00 | 304.00 |
| UHC to 5/31/2024 | 333.25 | 260.50 | 220.75 | ||
| UHC eff 6/1/2024 | 380.00 | 297.25 | 251.75 |
|
Prepared for
Zip code: 91361 Age: 77 |
|
UHC rates based on Part B effective less than 10 years
|