| Part A Hospital Services | A | B | C | G | G-ded | 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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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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 | |
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| Skilled nursing facility coinsurance | |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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% |
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| 3 Pints of (unreplaced) blood | |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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% |
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| Part B Services | A | B | C | G | G-ded | 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 | G | G-ded | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | $5120 | $2560 | NA | NA |
| Hospice coverage | |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | C | G | G-ded | K | L | M | N |
| Anthem | 278.33 | 345.78 | 372.03 | ||||||
| Blue Shield | 248.00 | S: 381.00 Extra Rider
E: 396.00 |
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| Continental (Aetna) | 318.04 | 402.09 | 412.92 | 309.96 | |||||
| Health Net | 271.00 | S: 345.00 Additional benefits included with Health Net Innovative plan rider
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133.00 | 263.00 | |||||
| Humana Achieve | 276.60 | 312.47 | 104.06 | 259.60 | |||||
| ManhattanLife | 318.67 | 320.25 | 274.67 | ||||||
| National Health Ins | 330.86 | 369.30 | 291.84 | ||||||
| Physicians Mutual | 262.44 | 310.88 | 258.35 | ||||||
| United American to 4/30/2024 | 212.00 | 302.00 | 432.00 | 366.00 | 93.00 | 187.00 | 264.00 | 300.00 | |
| United American eff 5/1/2024 | 217.00 | 309.00 | 454.00 | 393.00 | 102.00 | 187.00 | 264.00 | 329.00 | |
| UHC to 5/31/2024 | 185.50 | 259.00 | 312.25 | 245.25 | 172.25 | 207.75 | |||
| UHC eff 6/1/2024 | 207.00 | 288.75 | 348.25 | 273.75 | 192.00 | 231.75 |
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Prepared for
Zip code: 91201 Age: 81 |
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UHC rates based on Part B effective less than 10 years
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