California PHP

Benefits

Original Medicare

PHP

Doctor Office Visits

(includes visits to primary care and specialist providers)

20% coinsurance

(You pay 20% of the cost of the visit)

$0 copay per visit to primary care provider (PCP) or specialist.

Emergency Care

20% coinsurance for the doctor’s services.

Specified copayment for outpatient hospital facility emergency services.

Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.

You pay $100 copay per emergency room visit.

Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network.

Emergency care is only covered within the United States.

Urgently Needed Services

20% coinsurance, or a set copay.

$0 copay

Outpatient Services

20% coinsurance for the doctor’s services.

Specified copayment for outpatient hospital facility services. Copay cannot exceed Part A inpatient hospital deductible.

20% coinsurance for ambulatory surgical center facility services.

$0 copay for outpatient services.

Some services require referral and authorization.

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

20% coinsurance for diagnostic tests and x-rays.

$0 copay for Medicare-covered lab services.

You pay nothing for the following services:

• Diagnostic radiology services, e.g., MRI, CT, PET scans
• Lab services
• Diagnostic tests and procedures
• Outpatient x-rays
• Colonoscopy, sigmoidoscopy, endoscopy
• Radiation therapy

Referral required.

Inpatient Hospital Care

 In 2025, the amounts for each benefit period are:

• $1,676 deductible
• Days 1-60: $0 per day
• Days 61-90: $419 per day
• Days 91-150: $838 per lifetime reserve day

• $100 copay per day for days 1 through 6.
• $0 copay per day for days 7 through 90.

$0 copay per day for “lifetime reserve” days 91 through 150.

Skilled Nursing Facility (SNF)

In 2025, the amounts for each benefit period are:

• Day 1-20: $0 per day
• Days 21-100: $209.50 per day

Three-day inpatient hospital stay required before going into SNF.

• $0 copay per day for days 1 through 100.

No prior hospital stay is required.