| Part A Hospital Services | A | F | G |
|---|---|---|---|
| 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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| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
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| Skilled nursing facility coinsurance | |
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| 3 Pints of (unreplaced) blood | |
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| Part B Services | A | F | G |
| 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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| 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 | A | F | G |
| Out of Pocket Limit | NA | NA | NA |
| Hospice coverage | |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | F | G |
| Anthem | 211.61 | S: 393.21 I: Additional benefits included with Anthem Innovative plan rider
|
286.16 |
| Blue Shield eff 7/1/2024 | 205.00 | 416.00 | S: 339.00 Extra Rider
E: 355.00 |
| Health Net | 225.00 | S: 320.00 Additional benefits included with Health Net Innovative plan rider
|
S: 286.00 Additional benefits included with Health Net Innovative plan rider
|
| Physicians Mutual | 210.87 | 280.43 | 244.87 |
| UHC eff 6/1/2024 | 181.25 | 306.50 | 239.75 |
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Prepared for
Zip code: 94903 Age: 80 |
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UHC rates based on Part B effective less than 10 years
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