Part A Hospital Services F-ded G-ded
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)		 $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
 $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
  • 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		 $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
 $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
Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage
Skilled nursing facility coinsurance $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
 $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
3 Pints of (unreplaced) blood $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
 $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
Part B Services F-ded G-ded
Part B Annual Deductible ($240)

Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance
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 F-ded G-ded
Out of Pocket Limit NA NA
Hospice coverage $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
 $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
Foreign Travel Emergency
Monthly Rates & Brochures F-ded G-ded
Health Net 112.00 98.00
UHC

Prepared for DENISE O DONNEL
Zip code: 92653
Age: 70

UHC rates based on Part B effective less than 10 years