| Part A Hospital Services | A | B | C | F | G | K | L | M | N |
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| 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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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 | |
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| Skilled nursing facility coinsurance | |
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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% |
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| 3 Pints of (unreplaced) blood | |
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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% |
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| Part B Services | A | B | C | F | G | K | L | M | 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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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% |
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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 | A | B | C | F | G | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | $5120 | $2560 | NA | NA |
| Hospice coverage | |
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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% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | C | F | G | K | L | M | N |
| Anthem | 266.04 | S: 494.37 I: Additional benefits included with Anthem Innovative plan rider
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359.8 | 372.22 | |||||
| Blue Shield eff 7/1/2024 | 246.00 | 441.00 | S: 346.00 Extra Rider
E: 380.00 |
336 | |||||
| Blue Shield to 6/30/2024 | 246.00 | 408.00 | S: 320.00 Extra Rider
E: 352.00 |
311 | |||||
| Continental (Aetna) | 289.55 | 366.19 | 513.13 | 376.10 | 257.74 | ||||
| Health Net | 310.00 | S: 439.00 Additional benefits included with Health Net Innovative plan rider
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S: 349.00 Additional benefits included with Health Net Innovative plan rider
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319.00 | |||||
| United American to 4/30/2024 | 299.00 | 405.00 | 533.00 | 544.00 | 442.00 | 259.00 | 366.00 | 355.00 | |
| United American eff 5/1/2024 | 305.00 | 415.00 | 559.00 | 580.00 | 476.00 | 259.00 | 366.00 | 390.00 | |
| UHC to 5/31/2024 | 236.89 | 330.69 | 398.95 | 400.77 | 313.17 | 220.10 | 265.36 | ||
| UHC eff 6/1/2024 | 264.63 | 369.02 | 445.30 | 447.49 | 350.04 | 245.65 | 296.38 |
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Prepared for f
Zip code: 95928 Age: 67 Spouse: 69 |
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UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years
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