| 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: 698.91 I: Additional benefits included with Anthem Innovative plan rider
|
495.13 | 522.27 | ||
| Blue Shield eff 7/1/2024 | 752.00 | S: 631.00 Extra Rider
E: 664.00 |
602 | ||
| Blue Shield to 6/30/2024 | 691.00 | S: 580.00 Extra Rider
E: 610.00 |
553 | ||
| Health Net | S: 608.00 Additional benefits included with Health Net Innovative plan rider
|
263.00 | S: 481.00 Additional benefits included with Health Net Innovative plan rider
|
246.00 | 454.00 |
| Humana Achieve to 7/31/2024 | 476.26 | 418.37 | 146.29 | 338.52 | |
| Humana Achieve eff 8/1/2024 | 511.68 | 449.46 | 146.29 | 338.52 | |
| Physicians Mutual | 480.37 | 419.03 | 347.91 | ||
| United American | 632.00 | 126.00 | 526.00 | 126.00 | 436.00 |
| UHC to 5/31/2024 | 579.86 | 453.27 | 384.11 | ||
| UHC eff 6/1/2024 | 661.20 | 517.22 | 438.05 |
|
Prepared for
Zip code: 93063 Age: 74 Spouse: 76 |
|
UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years UHC rates reflect 7% You can take 7% off your monthly premiums if
|