| Part A Hospital Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | 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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
Plan covers 50% Part A deductible50% | |
| 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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|||
| 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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|
| Part B Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Part B Annual Deductible ($240) | |
|
||||||||||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
|
|
|
|
|
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
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 | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | NA | NA | NA | $5120 | $2560 | 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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
|
|
| Foreign Travel Emergency | |
|
|
|
|
|
|
|
|
|||
| Monthly Rates & Brochures | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Anthem | 211.61 | S: 393.21 I: Additional benefits included with Anthem Innovative plan rider
|
286.16 | 296.04 | ||||||||
| Blue Shield eff 7/1/2024 | 205.00 | 416.00 | S: 339.00 Extra Rider
E: 355.00 |
260 | ||||||||
| Health Net | 225.00 | 286.00 | S: 320.00 Additional benefits included with Health Net Innovative plan rider
|
138.00 | S: 286.00 Additional benefits included with Health Net Innovative plan rider
|
125.00 | 247.00 | |||||
| Humana Achieve to 7/31/2024 | 225.53 | 284.53 | 252.23 | 84.79 | 208.80 | |||||||
| United American | 190.00 | 271.00 | 397.00 | 361.00 | 411.00 | 89.00 | 344.00 | 89.00 | 163.00 | 231.00 | 288.00 | |
| UHC to 5/31/2024 | 162.25 | 226.50 | 273.25 | 274.50 | 214.50 | 150.75 | 181.75 | |||||
| UHC eff 6/1/2024 | 181.25 | 252.75 | 305.00 | 306.50 | 239.75 | 168.25 | 203.00 |
|
Prepared for
Zip code: 94903 Age: 80 |
|
UHC rates based on Part B effective less than 10 years
|