| Part A Hospital Services | F | F-ded | G | G-ded | 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) |
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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 |
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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 |
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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 | |
$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 |
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| 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 |
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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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| Part B Services | F | F-ded | G | G-ded | 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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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 | F | F-ded | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | 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 |
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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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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 276.45 I: Additional benefits included with Anthem Innovative plan rider
|
195.86 | 206.60 | ||
| Blue Shield eff 7/1/2024 | 246.00 | S: 199.00 Extra Rider
E: 215.00 |
192 | ||
| Blue Shield to 6/30/2024 | 229.00 | S: 185.00 Extra Rider
E: 200.00 |
179 | ||
| Continental (Aetna) | 280.47 | 52.48 | 205.50 | 148.44 | |
| Health Net | S: 229.00 Additional benefits included with Health Net Innovative plan rider
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99.00 | S: 204.00 Additional benefits included with Health Net Innovative plan rider
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89.00 | 176.00 |
| Humana Achieve | 199.22 | 171.54 | 60.44 | 135.49 | |
| Physicians Mutual | 219.80 | 192.06 | 159.92 | ||
| United American to 4/30/2024 | 244.00 | 44.00 | 199.00 | 44.00 | 160.00 |
| United American eff 5/1/2024 | 260.00 | 48.00 | 214.00 | 48.00 | 176.00 |
| UHC to 5/31/2024 | 231.04 | 180.50 | 152.95 | ||
| UHC eff 6/1/2024 | 257.64 | 201.40 | 170.62 |
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Prepared for ROGER ROBERSON
Zip code: 92008 Age: 69 |
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UHC rates based on Part B effective less than 10 years
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