| 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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$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 |
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$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 |
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$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 |
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$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 |
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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 | |
$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 |
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$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 |
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| 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 |
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$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 |
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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 | |
$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 |
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$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 |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 256.90 I: Additional benefits included with Anthem Innovative plan rider
|
186.98 | 193.44 | ||
| Blue Shield eff 7/1/2024 | 246.00 | S: 199.00 Extra Rider
E: 215.00 |
192 | ||
| Blue Shield to 6/30/2024 | 229.00 | S: 185.00 Extra Rider
E: 200.00 |
179 | ||
| Health Net | S: 229.00 Additional benefits included with Health Net Innovative plan rider
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99.00 | S: 204.00 Additional benefits included with Health Net Innovative plan rider
|
85.00 | 167.00 |
| Humana Achieve to 7/31/2024 | 180.25 | 155.24 | 54.82 | 122.66 | |
| Humana Achieve eff 8/1/2024 | 193.63 | 166.74 | 54.82 | 122.66 | |
| Physicians Mutual | 201.13 | 175.80 | 146.44 | ||
| United American | 304.00 | 56.00 | 250.00 | 56.00 | 205.00 |
| UHC to 5/31/2024 | 208.62 | 163.02 | 138.13 | ||
| UHC eff 6/1/2024 | 232.94 | 182.21 | 154.28 |
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Prepared for
Zip code: 94931 Age: 69 |
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UHC rates based on Part B effective less than 10 years
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