Leading the Way to a Better Medicare Advantage Plan

www.MyInStil.com n P.O. Box 916, Augusta, GA 30903-0916

If you have additional questions, please call us at 1-877-446-7845 seven days a week from 8:00 am to 8:00 pm (For the hearing impaired, TTY users call 1-800-503-3118.)

You can contact Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week to discuss all your Medicare Advantage options. (For the hearing impaired, TTY users call 1-877-486-2048.)

2008 Summary of Benefits x Low Country South CaroLinaINCARE PFFS

Code H4204 1011_022_02 (10/2007) Low Country, SCCMS Contract Number H4204

Leading the Way to a Better Medicare Advantage Plan

...InStil Health

SECTION I – INTRODUCTION

Summary of Benefits forInStil InCare

January 1, 2008 - December 31, 2008

Thank you for your interest in InStil InCare. Our plan is offered by InStil Health Insurance Company, aMedicare Advantage private fee-for-service organization.

This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or listevery limitation or every exclusion. To get a complete list of our benefits, please call InStil InCare and ask forthe “Evidence of Coverage.”

You Have Choices In Your Healthcare As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare Advantage private fee-for-service plan, like InStilInCare. You may have other options too. You make the choice. No matter what you decide, you are still in theMedicare program.

You may join or leave a plan only at certain times. Please call InStil InCare at the telephone number listed atthe end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users shouldcall 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.

How Can I Compare My Options? You can compare InStil InCare and the Original Medicare Plan using this Summary of Benefits. The charts inthis booklet list some important health benefits. For each benefit, you can see what our plan covers and whatthe Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, whichmay change from year to year.

Where Is InStil InCare Available? The services area for this plan includes: Bamberg, Berkeley, Charleston, Colleton, Dorchester, OrangeburgCounties, SC. You must live in one of these areas to join the plan.

Who Is Eligible To Join InStil InCare? You can join InStil InCare if you are entitled to Medicare Part A and enrolled in Medicare Part B and live inthe service area. However, individuals with End Stage Renal Disease are generally not eligible to enroll inInStil InCare unless they are members of our organization and have been since their dialysis began.

Can I Choose My Doctors? As a member of InStil InCare, you can use any Medicare doctor, specialist, or hospital that accepts Medicarepayment and accepts the terms, conditions and payment rate of the InStil Health Insurance Company plan.InStil Health Insurance Company has the right to determine if the service or treatment ordered by your healthcare provider is covered under the InStil Health Insurance Company plan.

1H4204 1011_022_02 (10/2007) Low Country, SC

Does My Plan Cover Medicare Part B or Part D Drugs? InStil InCare plan does cover Medicare Part B prescription drugs. InStil InCare does NOT cover Medicare PartD prescription drugs. As a member of InStil InCare you can receive prescription drug coverage by joininganother Prescription Drug Plan. You can only join one Medicare Prescription Drug Plan.

What Types of Drugs May Be Covered Under Medicare Part B?Outpatient prescription drugs that may be covered under Medicare Part B include, but are not limited to, thefollowing types of drugs. Contact InStil InCare for more details.

Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who couldbe the patient) under doctor supervision.

Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage renal disease (permanent kid-ney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

Injectable Drugs: Most injectable drugs administered incident to a physician’s service.

Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paidfor by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage,in a Medicare-certified facility.

Some Oral Cancer Drugs: If the same drug is available in injectable form.

Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusiondrugs provided through DME.

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Please call InStil Health Insurance Company for more information about this plan.

Visit us at www.MyInStil.com or, call us:

Customer Service Hours:Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, 8:00 a.m. - 8:00 p.m. Eastern

Current and Prospective members should call (877) 446-7845 for questions related to the Medicare Advantage program. (TTY/TDD (800) 503-3118.)

For more information about Medicare, please call 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit www.medicare.gov on the Web.

If you have special needs, this document may be available in other formats.


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SECTION II – SUMMARY OF BENEFITS

Benefit Category Original Medicare InStil InCare

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1 – Premium and Other ImportantInformation

A Medicare Advantage PrivateFee-for-Service plan works differently than a Medicaresupplement plan. Your doctoror hospital must agree to acceptthe plan’s terms and conditionsprior to providing health careservices to you, with the exception of emergencies. Ifyour doctor or hospital does notagree to accept our paymentterms and conditions, they maynot provide health care servicesto you, except in emergencies.Providers can find the plan’sterms and conditions on ourWeb site at: www.myinstil.com.

You pay the Medicare Part Bpremium of $96.40 each month.

Each year you pay a total of one$135 deductible.

If a doctor or supplier does notaccept assignment, their costs areoften higher, which means youpay more.

$40 monthly plan premium inaddition to your $96.40 monthlyMedicare Part B premium.

Balance billing means that aprovider may charge and billyou more than the plan’s pay-ment amount for services.

There is a limit on whatproviders may charge forMedicare-covered services.

$5,000 out-of-pocket limit.Contact the plan for servicesthat apply.

Unless otherwise noted, out-of-network services not covered.

2 – Doctor and Hospital Choice(For more information, seeEmergency #15 and UrgentlyNeeded Care #16.)

You may go to any doctor,specialist or hospital that acceptsMedicare.

You may have to pay a separatecopay for certain doctor officevisits.

You may go to any doctor,specialist or hospital that acceptsthe plan’s payment.

IMPORTANT INFORMATION



SUMMARY OF BENEFITS

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INPATIENT CARE

3 – Inpatient Hospital Care(includes Substance Abuse andRehabilitation Services)

For each benefit period:

Days 1-60: $1,024 deductible

Days 61-90: $256 per day

Days 91-150: $512 per lifetimereserve day

Please call 1-800-MEDICARE(1-800-633-4227) for informationabout lifetime reserve days.

Lifetime reserve days can only beused once.

A “benefit period” starts the dayyou go into a hospital or skillednursing facility. It ends when yougo for 60 days in a row withouthospital or skilled nursing care. Ifyou go into the hospital after onebenefit period has ended, a newbenefit period begins. You mustpay the inpatient hospitaldeductible for each benefit period.There is no limit to the number ofbenefit periods you can have.

You may go to any doctor,specialist, or hospital thataccepts the plan’s payment.

For Medicare-covered hospitalstays:

Days 1-7: $150 copay per day


$0 copay for additional hospitaldays.

No limit to the number of dayscovered by the plan each benefitperiod.

4 – Inpatient Mental Health Care Same deductible and copay asinpatient hospital care (see“Inpatient Hospital Care”above).

190 day limit in a PsychiatricHospital.

For hospital stays:Days 1-7: $150 copay per day


You get up to 190 days in aPsychiatric Hospital in a lifetime.



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5 – Skilled Nursing Facility (in a Medicare-certified skillednursing facility)

For each benefit period after atleast a 3-day covered hospitalstay:



100 days for each benefit period.

A “benefit period” starts the dayyou go into a hospital or SNF. Itends when you go for 60 days ina row without hospital or skillednursing care. If you go into thehospital after one benefit periodhas ended, a new benefit periodbegins. You must pay the inpa-tient hospital deductible for eachbenefit period. There is no limitto the number of benefit periodsyou can have.

For Medicare-covered SNFstays:



100 days covered for each benefit period.

3-day prior hospital stay isrequired.

6 – Home Health Care(includes medically necessaryintermittent skilled nursing care,home health aide services, andrehabilitation services, etc.)

$0 copay 20% of the cost for eachMedicare-covered home healthvisit.

7 – Hospice You pay part of the cost for out-patient drugs and inpatientrespite care.

You must receive care from aMedicare-certified hospice.

You must receive care from aMedicare-certified hospice.


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OUTPATIENT CARE

8 – Doctor Office Visits 20% coinsurance You may go to any doctor,specialist, or hospital thataccepts the plan’s payment.

See “Routine Physical Exams,”for more information.

$20 copay for each primary caredoctor visit for Medicare-cov-ered benefits.

$30 copay for each specialistvisit for Medicare-covered benefits.

9 – Chiropractic Services 20% coinsurance

Routine care not covered.

20% coinsurance for manualmanipulation of the spine tocorrect subluxation if you get itfrom a chiropractor or other qualified provider.

$30 copay for Medicare-covered visits.

Medicare-covered chiropracticvisits are for manual manipula-tion of the spine to correct a dis-placement or misalignment of ajoint or body part.

10 – Podiatry Services 20% coinsurance

Routine care not covered.

20% coinsurance for medicallynecessary foot care, includingcare for medical conditionsaffecting the lower limbs.

$30 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medicallynecessary foot care.



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11 – Outpatient Mental Health Care 50% coinsurance for most outpa-tient mental health services.

$30 copay for each Medicare-covered individual or grouptherapy visit.

12 – Outpatient Substance Abuse Care 20% coinsurance $30 copay for Medicare-coveredindividual or group visits.

13 – Outpatient Services/Surgery 20% coinsurance for the doctor.

20% of outpatient facility.

$100 copay for each Medicare-covered ambulatory surgicalcenter visit.

$100 copay for each Medicare-covered outpatient hospitalfacility visit.

Additional facility charges mayapply.

14 – Ambulance Service(medically necessary ambulanceservices)

20% coinsurance $50 copay for Medicare-covered ambulance benefits.

15 – Emergency Care (You may go to any emergencyroom if you reasonably believeyou need emergency care.)

20% coinsurance for the doctor.

20% of facility charge, or a setcopay per emergency room visit.

You don’t have to pay the emer-gency copay if you are admitted tothe hospital for the same conditionwithin 3 days of the emergencyroom visit.

NOT covered outside the U.S.except under limited circumstances.

$50 copay for each Medicare-covered emergency room visits.

$25,000 limit for emergencyservices outside the U.S. everyyear.

$250 copay for world-wide cov-erage will only be charged onceper calendar year.

Period for world-wide coverageis limited to 60 consecutive daysof foreign travel.


OUTPATIENT MEDICAL SERVICES AND SUPPLIES

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16 – Urgently Needed Care (This isNOT emergency care, and inmost cases, is out of the servicearea.)

20% coinsurance or a set copay.

NOT covered outside the U.S.except under limited circumstances.

$20 to $30 copay for Medicare-covered urgently needed care visits.

17 – Outpatient RehabilitationServices (Occupational Therapy,Physical Therapy, Speech andLanguage Therapy)

20% coinsurance $30 copay for Medicare-coveredOccupational Therapy visits.

$30 copay for Medicare-coveredPhysical Therapy and/orSpeech/Language Therapy visits.

18 – Durable Medical Equipment (includes wheelchairs, oxygen,etc.)

20% coinsurance 30% of the cost for Medicare-covered items.

19 – Prosthetic Devices (includesbraces, artificial limbs and eyes,etc.)

20% coinsurance 30% of the cost for Medicare-covered items.

20 – Diabetes Self-MonitoringTraining, Nutrition Therapy andSupplies (includes coverage forglucose monitors, test strips,lancets, screening tests and self-management training)

20% coinsurance 20% of the cost for Diabetesself-monitoring training.

$30 copay for Nutrition Therapyfor Diabetes.

20% of the cost for Diabetessupplies.


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21 – Diagnostic Tests, X-Rays, andLab Services

20% coinsurance for diagnostictests and x-rays.

$0 copay for Medicare-coveredlab services.

Lab Services: Medicare coversmedically necessary diagnosticlab services that are ordered byyour treating doctor when theyare provided by a ClinicalLaboratory ImprovementAmendments (CLIA) certifiedlaboratory that participates inMedicare. Diagnostic lab servicesare done to help your doctordiagnose or rule out a suspectedillness or condition. Medicaredoes not cover most routinescreening tests, like checkingyour cholesterol.

$30 copay for Medicare-covered lab services.

$30 copay for Medicare-covered diagnostic proceduresand tests.

$30 copay for Medicare-covered X-rays.

$30 copay for Medicare-covered diagnostic radiologyservices.

$30 copay for Medicare-covered therapeutic radiologyservices.

Additional facility charges mayapply.

Copayments apply only whendiagnostic procedures, tests, orlab services are obtained at afreestanding facility. If servicesare provided in a doctor’s officeor other medical facility (hospi-tal), then services are coveredunder the copay for the doctor’soffice visit or the facility charge.

22 – Bone Mass Measurement (forpeople with Medicare who areat risk)

20% coinsurance

Covered once every 24 months(more often if medically neces-sary) if you meet certain medical conditions.

$0 copay for Medicare-coveredbone mass measurement.

23 – Colorectal Screening Exams(for people with Medicare age50 and older)

20% coinsurance

Covered when you are highrisk or when you are age 50 andolder.

$0 copay for Medicare-covered colorectal screenings.

PREVENTIVE SERVICES



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24 – Immunizations (Flu vaccine,Hepatitis B vaccine – for people with Medicare who areat risk, Pneumonia vaccine)

$0 copay for the Flu andPneumonia vaccines.

20% coinsurance for HepatitisB vaccine.

You may only need thePneumonia vaccine once inyour lifetime. Call your doctorfor more information.

$0 copay for Flu and Pneumoniavaccines.

$0 copay for Hepatitis B vaccine.

25 – Mammograms (AnnualScreening) (for women withMedicare age 40 and older)

20% coinsurance No referral needed.

Covered once a year for allwomen with Medicare age 40and older. One baseline mam-mogram covered for womenwith Medicare between age 35and 39.

$0 copay for Medicare-coveredscreening mammograms.

26 – Pap Smears and Pelvic Exams(for women with Medicare)

$0 copay for Pap smears

Covered once every 2 years.

Covered once a year for womenwith Medicare at high risk.

20% coinsurance for PelvicExams.

$0 copay for Medicare-coveredpap smears and pelvic exams.

27 – Prostate Cancer Screening (formen with Medicare age 50 andolder)

20% coinsurance for the digitalrectal exam.

$0 copay for the PSA test;

20% coinsurance for other related services.

Covered once a year for all menwith Medicare over age 50.

$0 copay for Medicare-coveredprostate cancer screenings.


ADDITIONAL BENEFITS (WHAT ORIGINAL MEDICARE DOES NOT COVER)

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28 – ESRD 20% coinsurance for dialysis.

Drugs covered under MedicarePart B

Most drugs not covered.

20% of the cost for Part B covered drugs (not includingPart B covered chemotherapydrugs).

20% of the cost for Part B covered chemotherapy drugs.

Drugs covers under MedicarePart D

This plan does not offer prescription drug coverage.

20% of the cost for in and out-of-area dialysis.

$30 copay for Nutrition Therapyfor Renal Disease.

30 – Dental Services Preventive dental services (suchas cleaning) not covered.

In general, preventive dentalbenefits (such as cleaning) notcovered.

20% of the cost for Medicare-covered dental benefits.

31 – Hearing Services Routine hearing exams and hearing aids not covered.

20% coinsurance for diagnostichearing exams.

In general, routine hearing examsand hearing aids not covered.

$30 copay for diagnostic hearingexams.

29 – Prescription Drugs Most drugs not covered. (Youcan add prescription drug cover-age to Original Medicare byjoining a Medicare PrescriptionDrug Plan.)



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33 – Physical Exams 20% coinsurance for one examwithin the first 6 months of yournew Part B coverage. When youget Medicare Part B, you can geta one time physical exam withinthe first 6 months of your newPart B coverage. The coveragedoes not include lab tests.

$0 copay for routine exams.

Limited to 1 exam(s) every year.

34 – Health/Wellness Education Not covered. This plan covers health/wellnesseducation benefits.

• Written health educationmaterials, includingNewsletters

• Nutritional Training

• Smoking Cessation

• Alternative Medicine

Program

• Nursing Hotline

• Other Wellness Benefits

Supplemental benefits include acongestive heart program andother disease management programs.

32 – Vision Services 20% coinsurance for diagnosisand treatment of diseases andconditions of the eye.

Routine eye exams and glassesnot covered.

Annual glaucoma screeningscovered for people at risk.

Medicare pays for one pair ofeyeglasses or contact lenses aftereach cataract surgery.

Non-Medicare-covered eyeexams and glasses not covered.

$30 copay for one pair of eye-glasses or contact lenses aftereach cataract surgery.

$30 copay for exams to diag-nose and treat diseases and conditions of the eye.

Documents

Leading the Way to a Better Medicare Advantage Plan