| 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: 267.20 I: Additional benefits included with Anthem Innovative plan rider
|
194.45 | 201.16 | ||
| Blue Shield eff 7/1/2024 | 257.00 | S: 212.00 Extra Rider
E: 229.00 |
204 | ||
| Blue Shield to 6/30/2024 | 240.00 | S: 198.00 Extra Rider
E: 214.00 |
191 | ||
| Health Net | S: 229.00 Additional benefits included with Health Net Innovative plan rider
|
99.00 | S: 204.00 Additional benefits included with Health Net Innovative plan rider
|
85.00 | 167.00 |
| Humana Achieve to 7/31/2024 | 182.77 | 158.00 | 56.31 | 124.15 | |
| Humana Achieve eff 8/1/2024 | 196.33 | 169.71 | 56.31 | 124.15 | |
| Physicians Mutual | 208.48 | 182.19 | 151.77 | ||
| United American | 319.00 | 58.00 | 263.00 | 58.00 | 217.00 |
| UHC to 5/31/2024 | 216.86 | 169.46 | 143.58 | ||
| UHC eff 6/1/2024 | 242.14 | 189.40 | 160.37 |
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Prepared for
Zip code: 94931 Age: 70 |
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UHC rates based on Part B effective less than 10 years
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