| 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: 429.05 I: Additional benefits included with Anthem Innovative plan rider
|
307.98 | 331.37 | ||
| Blue Shield eff 7/1/2024 | 429.00 | S: 355.00 Extra Rider
E: 372.00 |
310 | ||
| Blue Shield to 6/30/2024 | 398.00 | S: 329.00 Extra Rider
E: 345.00 |
287 | ||
| Health Net | S: 341.00 Additional benefits included with Health Net Innovative plan rider
|
148.00 | S: 303.00 Additional benefits included with Health Net Innovative plan rider
|
137.00 | 270.00 |
| Humana Achieve to 7/31/2024 | 316.13 | 279.41 | 95.06 | 229.35 | |
| Humana Achieve eff 8/1/2024 | 339.70 | 300.22 | 95.06 | 229.35 | |
| Physicians Mutual | 326.43 | 284.94 | 236.86 | ||
| United American | 336.00 | 68.00 | 281.00 | 68.00 | 234.00 |
| UHC to 5/31/2024 | 313.75 | 245.25 | 207.75 | ||
| UHC eff 6/1/2024 | 350.00 | 273.75 | 231.75 |
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Prepared for
Zip code: 91607 Age: 78 |
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UHC rates based on Part B effective less than 10 years
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