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Part A Hospital Services	F	F-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)		$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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		$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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		$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded
3 Pints of (unreplaced) blood		$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded
Part B Services	F	F-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	F-ded
Out of Pocket Limit	NA	NA
Hospice coverage		$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded
Foreign Travel Emergency
Monthly Rates & Brochures	F	F-ded
Anthem CKHH	S: 327.28 I: Additional benefits included with Anthem Innovative plan rider Vision Benefits Routine eye exam In network: No Charge Out of network: $35 Allowance Eyeglass Frames In network: $100 allowance Out of network: $45 Allowance Eyeglass Lenses Single vision - In network:100% coverage after $25 copay Out of network:$25 benefit after $25 copay Bifocal - In network:100% coverage after $25 copay Out of network:$40 benefit after $25 copay Trifocal or Lenticular - In network:100% coverage after $25 copay Out of network:$55 benefit after $25 copay Contact Lenses In network: $100 allowance Out of network: $80 Allowance Hearing Benefits Coverage through Hearing Care Solutions Hearing exam: 100% coverage Hearing aids: Coverage allowance up to $750 per year Other Innovative Plan Benefits Nurse help line: Speak with a Registered nurse about health related questions Other Benefits (included with both Standard and Innovative Plans) SilverSneakers gym membership See page 21 or 22 in Anthem brochure for details 314.11
Blue Shield eff 7/1/2024 CKHH	286.00
Blue Shield to 6/30/2024 CKHH	269.00
Choosing a Medigap Policy

Part A Hospital Services

F-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)

$2800 annual deductible applies

You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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

$2800 annual deductible applies

You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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

$2800 annual deductible applies

You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year

After that coverage is 100%

after
ded

3 Pints of (unreplaced) blood

$2800 annual deductible applies

You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year

After that coverage is 100%

after
ded

Part B Services

F-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

Out of Pocket Limit

Hospice coverage

$2800 annual deductible applies

You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year

After that coverage is 100%

after
ded

Foreign Travel Emergency

Monthly Rates & Brochures

F-ded

Anthem CKHH

S: 327.28
I: Additional benefits included with Anthem Innovative plan rider

Vision Benefits
Routine eye exam In network: No Charge Out of network: $35 Allowance
Eyeglass Frames In network: $100 allowance Out of network: $45 Allowance
Eyeglass Lenses
- Single vision - In network:100% coverage after $25 copay Out of network:$25 benefit after $25 copay
- Bifocal - In network:100% coverage after $25 copay Out of network:$40 benefit after $25 copay
- Trifocal or Lenticular - In network:100% coverage after $25 copay Out of network:$55 benefit after $25 copay
Contact Lenses In network: $100 allowance Out of network: $80 Allowance
Hearing Benefits Coverage through Hearing Care Solutions
Hearing exam: 100% coverage
Hearing aids: Coverage allowance up to $750 per year
Other Innovative Plan Benefits
Nurse help line: Speak with a Registered nurse about health related questions
Other Benefits (included with both Standard and Innovative Plans)
SilverSneakers gym membership

See page 21 or 22 in Anthem brochure for details

314.11

Blue Shield eff 7/1/2024 CKHH

286.00

Blue Shield to 6/30/2024 CKHH

269.00

Choosing a Medigap Policy

Select all that apply

Anthem $2 per month
Blue Shield $3 per month

Automatic Checking Withdrawal Discount

If you are new to Medicare the following monthly discounts
are available for your first year of coverage

Anthem Plan F: $20 Plans G: $25 per month
Blue Shield Plans A. F and G: $25 per month

Welcome to Medicare discount 2 party

Anthem Plan F rates reflect $20 Welcome to Medicare discount.

Anthem Plan F rates reflect $40 2 party Welcome to Medicare discount.

Anthem Plan G rates reflect $25 Welcome to Medicare discount.

Anthem Plan G rates reflect $50 2 party Welcome to Medicare discount.

Enrollees who live with another Anthem Medicare Supplement
member may qualify for a household discount.

For members with an original Anthem Blue Cross
effective date after 2/28/2023 the discount is 10%
For those with original effective dates between
6/1/2010 and 2/28/2023 the discount is 5%
The household discount is not available to persons
enrolled before 6/1/2010

Anthem household discount

Anthem rates reflect $2 automatic checking discount.

Blue Shield Plan G rates reflect $25 Welcome to Medicare discount.

Blue Shield Plan G rates reflect $50 2 party Welcome to Medicare discount.

Blue Shield rates reflect $3 automatic checking discount.

Blue ShieldYou are eligible for a 7% household premium discount

if you reside with another person who is on the same Blue Shield Medicare Supplement plan
including same Dental plan.

Only one policy will be issued, the second party will be covered as a dependent. household discount (7%)

Continental Life You are be eligible for a 5% discount if you reside with another
person covered by Continental Life who is either
(a) your spouse;
(b) someone with whom you are in a civil union partnership;
(c) a permanent resident in your home.5% household discount

Humana Achieve rates reflect $2 automatic checking discount.

Physicians Mutual rates reflect $5 automatic checking discount.

UHC Plan G rates reflect $25 Welcome to Medicare discount.

UHC Plan G rates reflect $50 2 party Welcome to Medicare discount.

United Healthcare rates reflect $2 automatic checking discount.