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Part A Hospital Services	G	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)
The inpatient deductible is $1632 for each benefit period Days 1-60: Medicare covers 100% Days 61-90: You are responsible for $408 per day Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day Beyond lifetime reserve: You are responsible for all costs incurred Hospital Coinsurance
Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage
Skilled nursing facility coinsurance
3 Pints of (unreplaced) blood
Part B Services	G	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	G	N
Out of Pocket Limit	NA	NA
Hospice coverage
Foreign Travel Emergency
Monthly Rates & Brochures	G	N
Blue Shield eff 7/1/2024 CKHH	S: 268.77 Note: Silver Sneakers gym membership is included with all Blue Shield plans. Additonal benefits with Blue Shield Extra Rider Foreign Travel - Not covered by Medicare $250 annual deductible, 80% coverage, $50,000 lifetime max (Click the Brochure link, see page 20) Physician Consultation by Phone or Video Through Teledoc No charge (see brochure page 20) Over-the-Counter Items through CVS Up to $100 allowance per quarter (see brochure page 20) Accupuncture and Chiropractic Services (provided by AHS provider network) Up to 20 visits per year, plan pays 100%, see page 21 in brochure for details Vision Coverage (provided by Vision Service Plan) Exam every 12 months, eyeglasses every 24 months, click the brochure link for details (see page 21) Hearing Aid Services (provided by Epic Hearing Healthcare) Routine hearing exams, copayments for hearing aids, see page 23 of brochure for details E: 283.65	252.03
Choosing a Medigap Policy

Part A Hospital Services

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)

The inpatient deductible is $1632 for each benefit period
Days 1-60: Medicare covers 100%
Days 61-90: You are responsible for $408 per day
Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day
Beyond lifetime reserve: You are responsible for all costs incurred

Hospital Coinsurance

Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage

Skilled nursing facility coinsurance

3 Pints of (unreplaced) blood

Part B Services

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

Out of Pocket Limit

Hospice coverage

Foreign Travel Emergency

Monthly Rates & Brochures

Blue Shield eff 7/1/2024 CKHH

S: 268.77

Note: Silver Sneakers gym membership is included with all Blue Shield plans.

Additonal benefits with Blue Shield Extra Rider

Foreign Travel - Not covered by Medicare

$250 annual deductible, 80% coverage, $50,000 lifetime max (Click the Brochure link, see page 20)

Physician Consultation by Phone or Video Through Teledoc

No charge (see brochure page 20)

Over-the-Counter Items through CVS

Up to $100 allowance per quarter (see brochure page 20)

Accupuncture and Chiropractic Services (provided by AHS provider network)

Up to 20 visits per year, plan pays 100%, see page 21 in brochure for details

Vision Coverage (provided by Vision Service Plan)

Exam every 12 months, eyeglasses every 24 months, click the brochure link for details (see page 21)

Hearing Aid Services (provided by Epic Hearing Healthcare)

Routine hearing exams, copayments for hearing aids, see page 23 of brochure for details

E: 283.65

252.03

Choosing a Medigap Policy

Select all that apply

Blue Shield $3 per month

Automatic Checking Withdrawal Discount

If you are new to Medicare the following monthly discounts
are available for your first year of coverage

Blue Shield Plans A. F and G: $25 per month

Welcome to Medicare discount 2 party

Anthem rates reflect $2 automatic checking discount.

Blue Shield Plan G rates reflect $25 Welcome to Medicare discount.

Blue Shield Plan G rates reflect $50 2 party Welcome to Medicare discount.

Blue Shield rates reflect $3 automatic checking discount.

Blue ShieldYou are eligible for a 7% household premium discount

if you reside with another person who is on the same Blue Shield Medicare Supplement plan
including same Dental plan.

Only one policy will be issued, the second party will be covered as a dependent. household discount (7%)

Humana Achieve rates reflect $2 automatic checking discount.

Physicians Mutual rates reflect $5 automatic checking discount.

UHC Plan G rates reflect $25 Welcome to Medicare discount.

UHC Plan G rates reflect $50 2 party Welcome to Medicare discount.

United Healthcare rates reflect $2 automatic checking discount.