| Part A Hospital Services | F | F-ded | G | G-ded | 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 |
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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: 382.26 I: Additional benefits included with Anthem Innovative plan rider
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274.38 | 295.21 | ||
| Blue Shield eff 7/1/2024 | 349.00 | S: 294.00 Extra Rider
E: 310.00 |
273 | ||
| Blue Shield to 6/30/2024 | 329.00 | S: 277.00 Extra Rider
E: 292.00 |
257 | ||
| Health Net | S: 320.00 Additional benefits included with Health Net Innovative plan rider
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138.00 | S: 286.00 Additional benefits included with Health Net Innovative plan rider
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127.00 | 250.00 |
| Humana Achieve | 283.23 | 248.52 | 87.55 | 200.76 | |
| Physicians Mutual | 299.15 | 261.19 | 217.18 | ||
| United American to 4/30/2024 | 397.00 | 78.00 | 327.00 | 78.00 | 265.00 |
| United American eff 5/1/2024 | 422.00 | 85.00 | 352.00 | 85.00 | 291.00 |
| UHC to 5/31/2024 | 294.93 | 230.54 | 195.29 | ||
| UHC eff 6/1/2024 | 329.00 | 257.33 | 217.85 |
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Prepared for SUSAN NIHISER
Zip code: 91356 Age: 75 |
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UHC rates based on Part B effective less than 10 years
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