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RI81077RD
Outline of Medicare Supplement Coverage
Humana Reader’s Digest Healthy Living Medicare Supplement Plan
for Rhode Island residents Medicare supplement benefit plans with Dental and Vision: A, F, High Deductible F, K, and N
RI81077RD 1
Hum
ana
Read
er’s
Dig
est
Hea
lthy
Liv
ing
Med
icar
e Su
pple
men
t In
sura
nce
Plan
s H
uman
a In
sura
nce
Com
pany
off
ers
Plan
s A
, F, H
igh
Ded
ucti
ble
F, K
and
NBe
nefi
t Ch
art
of M
edic
are
Supp
lem
ent
Plan
s So
ld o
n or
Aft
er J
une
1, 2
010
This
char
t sho
ws
the
bene
fits
incl
uded
in e
ach
of th
e st
anda
rd M
edic
are
supp
lem
ent p
lans
. Eve
ry c
ompa
ny m
ust m
ake
Plan
“A
” av
aila
ble.
Som
e pl
ans
may
not
be
avai
labl
e in
you
r sta
te.
Basi
c Be
nefi
ts:
•H
ospi
taliz
atio
n: P
art A
coi
nsur
ance
plu
s co
vera
ge fo
r 365
add
ition
al d
ays
afte
r Med
icar
e be
nefit
s en
d.•
Med
ical
Exp
ense
s:P
art B
coi
nsur
ance
(gen
eral
ly 2
0% o
f Med
icar
e-ap
prov
ed e
xpen
ses)
or c
opay
men
ts fo
r hos
pita
l out
patie
nt s
ervi
ces.
Pla
ns K
, L,
and
N re
quire
insu
reds
to p
ay a
por
tion
of P
art B
coi
nsur
ance
or c
opay
men
ts.
•Bl
ood:
Firs
t thr
ee p
ints
of b
lood
eac
h ye
ar.
•H
ospi
ce: P
art A
coi
nsur
ance
AB
CD
FF*
GK
LM
NBa
sic,
inclu
ding
10
0% P
art B
co
insu
ranc
e
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce*
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce
Hos
pita
liza-
tion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basic
ben
efits
pa
id a
t 50%
Hos
pita
liza-
tion
and
prev
entiv
e ca
re p
aid
at
100%
; oth
er
basic
ben
efits
pa
id a
t 75%
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce
Basic
, in
cludi
ng
100%
Par
t B
coin
sura
nce,
ex
cept
up
to $
20
copa
ymen
t fo
r offi
ce v
isit,
and
up to
$5
0 fo
r ER
Skille
d N
ursin
g Fa
cility
C
oins
uran
ce
Skille
d N
ursin
g Fa
cility
C
oins
uran
ce
Skille
d N
ursin
g Fa
cility
C
oins
uran
ce
Skille
d N
ursin
g Fa
cility
C
oins
uran
ce
50%
Ski
lled
Nur
sing
Facil
ity
Coi
nsur
ance
75%
Ski
lled
Nur
sing
Facil
ity
Coi
nsur
ance
Skille
d N
ursin
g Fa
cility
C
oins
uran
ce
Skille
d N
ursin
g Fa
cility
C
oins
uran
cePa
rt A
D
educ
tible
Part
A
Ded
uctib
lePa
rt A
D
educ
tible
Part
A
Ded
uctib
lePa
rt A
D
educ
tible
50%
Par
t A
Ded
uctib
le75
% P
art A
D
educ
tible
50%
Par
t A
Ded
uctib
lePa
rt A
D
educ
tible
Part
B D
educ
tible
Part
B D
educ
tible
Part
B Ex
cess
(1
00%
)Pa
rt B
Exce
ss
(100
%)
Fore
ign
Trav
el
Emer
genc
yFo
reig
n Tr
avel
Em
erge
ncy
Fore
ign
Trav
el
Emer
genc
yFo
reig
n Tr
avel
Em
erge
ncy
Fore
ign
Trav
el
Emer
genc
yFo
reig
n Tr
avel
Em
erge
ncy
Inno
vativ
e Be
nefit
sIn
nova
tive
Bene
fits
Inno
vativ
e Be
nefit
sIn
nova
tive
Bene
fits
* Pla
n F
also
has
an
optio
n ca
lled
a hi
gh d
educ
tible
pla
n F.
This
high
ded
uctib
le p
lan
pays
th
e sa
me
bene
fits a
s Pla
n F
afte
r one
has
pai
d a
cale
ndar
yea
r $2,
110
dedu
ctib
le. B
enefi
ts
from
hig
h de
duct
ible
pla
n F
will
not b
egin
unt
il ou
t-of-p
ocke
t exp
ense
s exc
eed
$2,1
10.
Out
-of-p
ocke
t exp
ense
s for
this
dedu
ctib
le a
re e
xpen
ses t
hat w
ould
ord
inar
ily b
e pa
id b
y th
e po
licy.
Thes
e ex
pens
es in
clude
the
Med
icare
ded
uctib
les f
or P
art A
and
Par
t B, b
ut d
o no
t in
clude
the
plan
’s se
para
te fo
reig
n tra
vel e
mer
genc
y de
duct
ible
.
Out
-of-
pock
et li
mit
$4,8
00; p
aid
at 1
00%
af
ter l
imit
reac
hed
Out
-of-
pock
et li
mit
$2,4
00; p
aid
at 1
00%
af
ter l
imit
reac
hed
2 RI81077RD
HU
MA
NA
REA
DER
’SD
IGES
TH
EALT
HY
LIV
ING
MED
ICA
RES
UPP
LEM
ENT
STAT
EWID
EM
ON
THLY
PRE
MIU
MS
Effe
ctiv
eD
ate:
04-
01-2
012
Att
aine
d A
ge
& G
ende
rPl
an A
Plan
FH
igh
Ded
ucti
ble
Plan
F
Plan
KPl
an N
65-M
ale
Pref
erre
d$1
30.8
1$1
60.3
7$7
1.94
$83.
33$1
20.0
5St
anda
rd$1
89.8
6$2
34.0
3$1
01.8
6$1
18.8
9$1
73.7
8
65-F
emal
ePr
efer
red
$130
.51
$159
.99
$71.
78$8
3.15
$119
.77
Stan
dard
$189
.40
$233
.47
$101
.63
$118
.62
$173
.36
66-M
ale
Pref
erre
d$1
35.5
9$1
66.3
2$7
4.36
$86.
21$1
24.3
9St
anda
rd$1
97.0
0$2
42.9
4$1
05.4
8$1
23.1
9$1
80.2
7
66-F
emal
ePr
efer
red
$134
.08
$164
.44
$73.
59$8
5.30
$123
.02
Stan
dard
$194
.74
$240
.13
$104
.34
$121
.84
$178
.22
67-M
ale
Pref
erre
d$1
40.5
5$1
72.5
1$7
6.87
$89.
19$1
28.9
1St
anda
rd$2
04.4
1$2
52.1
9$1
09.2
4$1
27.6
6$1
87.0
1
67-F
emal
ePr
efer
red
$138
.99
$170
.57
$76.
08$8
8.26
$127
.49
Stan
dard
$202
.08
$249
.28
$108
.06
$126
.26
$184
.90
68-M
ale
Pref
erre
d$1
45.7
1$1
78.9
5$7
9.49
$92.
30$1
33.6
1St
anda
rd$2
12.1
3$2
61.8
2$1
13.1
5$1
32.3
1$1
94.0
4
68-F
emal
ePr
efer
red
$144
.08
$176
.93
$78.
66$9
1.33
$132
.13
Stan
dard
$209
.70
$258
.79
$111
.92
$130
.84
$191
.83
69-M
ale
Pref
erre
d$1
51.0
8$1
85.6
5$8
2.21
$95.
54$1
38.4
9St
anda
rd$2
20.1
5$2
71.8
2$1
17.2
2$1
37.1
4$2
01.3
4
69-F
emal
ePr
efer
red
$148
.06
$181
.89
$80.
68$9
3.72
$135
.75
Stan
dard
$215
.65
$266
.20
$114
.93
$134
.42
$197
.24
70-M
ale
Pref
erre
d$1
56.6
6$1
92.6
2$8
5.04
$98.
90$1
43.5
7St
anda
rd$2
28.5
0$2
82.2
4$1
21.4
5$1
42.1
7$2
08.9
3
70-F
emal
ePr
efer
red
$152
.18
$187
.02
$82.
77$9
6.20
$139
.49
Stan
dard
$221
.79
$273
.88
$118
.05
$138
.13
$202
.83
71-M
ale
Pref
erre
d$1
62.4
7$1
99.8
7$8
7.98
$102
.40
$148
.86
Stan
dard
$237
.18
$293
.07
$125
.85
$147
.39
$216
.83
71-F
emal
ePr
efer
red
$156
.39
$192
.28
$84.
90$9
8.74
$143
.33
Stan
dard
$228
.10
$281
.74
$121
.24
$141
.92
$208
.57
(Con
tinue
d on
nex
t pag
e)
RI81077RD 3
HU
MA
NA
REA
DER
’SD
IGES
TH
EALT
HY
LIV
ING
MED
ICA
RES
UPP
LEM
ENT
STAT
EWID
EM
ON
THLY
PRE
MIU
MS
Effe
ctiv
eD
ate:
04-
01-2
012
Att
aine
d A
ge
& G
ende
rPl
an A
Plan
FH
igh
Ded
ucti
ble
Plan
F
Plan
KPl
an N
72-M
ale
Pref
erre
d$1
68.5
2$2
07.4
1$9
1.05
$106
.04
$154
.36
Stan
dard
$246
.21
$304
.34
$130
.43
$152
.84
$225
.05
72-F
emal
ePr
efer
red
$160
.74
$197
.71
$87.
11$1
01.3
6$1
47.2
9St
anda
rd$2
34.6
0$2
89.8
5$1
24.5
4$1
45.8
4$2
14.4
8
73-M
ale
Pref
erre
d$1
74.8
0$2
15.2
4$9
4.23
$109
.82
$160
.07
Stan
dard
$255
.60
$316
.05
$135
.18
$158
.49
$233
.59
73-F
emal
ePr
efer
red
$165
.21
$203
.29
$89.
37$1
04.0
5$1
51.3
5St
anda
rd$2
41.2
8$2
98.1
9$1
27.9
2$1
49.8
6$2
20.5
6
74-M
ale
Pref
erre
d$1
81.3
3$2
23.4
0$9
7.54
$113
.76
$166
.02
Stan
dard
$265
.37
$328
.24
$140
.13
$164
.37
$242
.48
74-F
emal
ePr
efer
red
$169
.84
$209
.05
$91.
72$1
06.8
4$1
55.5
6St
anda
rd$2
48.1
9$3
06.8
0$1
31.4
3$1
54.0
2$2
26.8
5
75-M
ale
Pref
erre
d$1
88.1
4$2
31.8
9$1
00.9
9$1
17.8
6$1
72.2
1St
anda
rd$2
75.5
4$3
40.9
3$1
45.2
9$1
70.5
0$2
51.7
4
75-F
emal
ePr
efer
red
$174
.59
$214
.99
$94.
13$1
09.7
0$1
59.8
9St
anda
rd$2
55.3
0$3
15.6
8$1
35.0
3$1
58.3
1$2
33.3
2
76-M
ale
Pref
erre
d$1
95.2
0$2
40.7
0$1
04.5
7$1
22.1
1$1
78.6
3St
anda
rd$2
86.1
0$3
54.1
0$1
50.6
4$1
76.8
6$2
61.3
4
76-F
emal
ePr
efer
red
$179
.49
$221
.09
$96.
61$1
12.6
5$1
64.3
4St
anda
rd$2
62.6
1$3
24.8
0$1
38.7
4$1
62.7
1$2
39.9
7
77-M
ale
Pref
erre
d$2
02.5
5$2
49.8
6$1
08.2
9$1
26.5
4$1
85.3
2St
anda
rd$2
97.0
8$3
67.8
0$1
56.2
1$1
83.4
7$2
71.3
3
77-F
emal
ePr
efer
red
$184
.52
$227
.37
$99.
16$1
15.6
8$1
68.9
1St
anda
rd$2
70.1
3$3
34.1
8$1
42.5
5$1
67.2
4$2
46.8
1
78-M
ale
Pref
erre
d$2
08.2
9$2
57.0
2$1
11.2
0$1
29.9
9$1
90.5
4St
anda
rd$3
05.6
6$3
78.5
0$1
60.5
5$1
88.6
4$2
79.1
4
78-F
emal
ePr
efer
red
$189
.71
$233
.85
$101
.79
$118
.81
$173
.64
Stan
dard
$277
.90
$343
.87
$146
.48
$171
.92
$253
.88
(Con
tinue
d on
nex
t pag
e)
4 RI81077RD
HU
MA
NA
REA
DER
’SD
IGES
TH
EALT
HY
LIV
ING
MED
ICA
RES
UPP
LEM
ENT
STAT
EWID
EM
ON
THLY
PRE
MIU
MS
Effe
ctiv
eD
ate:
04-
01-2
012
Att
aine
d A
ge
& G
ende
rPl
an A
Plan
FH
igh
Ded
ucti
ble
Plan
F
Plan
KPl
an N
79-M
ale
Pref
erre
d$2
14.2
0$2
64.4
0$1
14.2
0$1
33.5
5$1
95.9
2St
anda
rd$3
14.4
9$3
89.5
2$1
65.0
3$1
93.9
6$2
87.1
7
79-F
emal
ePr
efer
red
$193
.29
$238
.31
$103
.60
$120
.96
$176
.89
Stan
dard
$283
.24
$350
.53
$149
.19
$175
.13
$258
.74
80-M
ale
Pref
erre
d$2
20.2
7$2
71.9
8$1
17.2
8$1
37.2
1$2
01.4
5St
anda
rd$3
23.5
7$4
00.8
5$1
69.6
3$1
99.4
3$2
95.4
4
80-F
emal
ePr
efer
red
$196
.91
$242
.83
$105
.44
$123
.14
$180
.19
Stan
dard
$288
.65
$357
.29
$151
.93
$178
.39
$263
.66
81-M
ale
Pref
erre
d$2
26.5
4$2
79.7
9$1
20.4
5$1
40.9
9$2
07.1
5St
anda
rd$3
32.9
4$4
12.5
3$1
74.3
8$2
05.0
7$3
03.9
6
81-F
emal
ePr
efer
red
$200
.63
$247
.48
$107
.32
$125
.38
$183
.58
Stan
dard
$294
.22
$364
.23
$154
.76
$181
.75
$268
.73
82-M
ale
Pref
erre
d$2
32.9
9$2
87.8
4$1
23.7
2$1
44.8
7$2
13.0
2St
anda
rd$3
42.5
8$4
24.5
6$1
79.2
7$2
10.8
7$3
12.7
3
82-F
emal
ePr
efer
red
$204
.41
$252
.19
$109
.24
$127
.66
$187
.01
Stan
dard
$299
.86
$371
.27
$157
.62
$185
.15
$273
.86
83-M
ale
Pref
erre
d$2
39.6
4$2
96.1
4$1
27.1
0$1
48.8
8$2
19.0
7St
anda
rd$3
52.5
2$4
36.9
7$1
84.3
1$2
16.8
6$3
21.7
8
83-F
emal
ePr
efer
red
$208
.27
$257
.00
$111
.19
$129
.98
$190
.53
Stan
dard
$305
.63
$378
.47
$160
.54
$188
.62
$279
.11
84-M
ale
Pref
erre
d$2
46.4
8$3
04.6
8$1
30.5
6$1
53.0
0$2
25.3
0St
anda
rd$3
62.7
5$4
49.7
2$1
89.4
9$2
23.0
2$3
31.0
8
84-F
emal
ePr
efer
red
$212
.22
$261
.93
$113
.19
$132
.36
$194
.12
Stan
dard
$311
.53
$385
.83
$163
.53
$192
.17
$284
.48
85+-
Mal
ePr
efer
red
$253
.54
$313
.49
$134
.14
$157
.25
$231
.72
Stan
dard
$373
.30
$462
.89
$194
.84
$229
.38
$340
.68
85+-
Fem
ale
Pref
erre
d$2
16.2
3$2
66.9
3$1
15.2
3$1
34.7
8$1
97.7
7St
anda
rd$3
17.5
3$3
93.3
1$1
66.5
7$1
95.7
8$2
89.9
3
RI81077RD 5
Premium Information
We, Humana Insurance Company, can only change the renewal premium for your policy if we also change the renewal premium for all policies that we issue like yours in this State. No change in premium will be made because of the number of claims you file, nor because of a change in your health or your type of work.
Your premiums will also be adjusted annually following your 66th birthday.
Disclosure
Use this outline to compare benefits and premiums among policies.
Read your policy very carefully
This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company.
Right to return policy
If you find that you are not satisfied with your policy, you may return it to:
Humana Insurance Company Attn: Medicare Enrollments P.O. Box 14168 Lexington, KY 40512-4168 If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments less any claims paid.
Policy replacement
If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.
Notice
This policy may not fully cover all of your medical costs.
Neither Humana Insurance Company nor its agents are connected with Medicare.
This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult the “Medicare & You” handbook for more details.
Humana offers Medicare Supplement Insurance plans that do not contain innovative benefits. For more information, please contact Humana at 1-888-310-8482.
Complete answers are very important
When you fill out the application for the new policy, be sure to truthfully and completely answer all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.
Review the application carefully before you sign it. Be certain that all information has been properly recorded.
6 RI81077RD
PLAN AMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays YouPayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,184 $0 $1,184 (Part A deductible)
61st through 90th day All but $296 a day $296 a day $0
91st day and after: while using 60 lifetime reserve days once lifetime reserve days are used:
- additional 365 days
All but $592 a day
$0
$592 a day
100% of Medicare eligible expenses
$0
$0**
- beyond the additional 365 days $0 $0 All costs
SKILLEDNURSINGFACILITYCARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st through 100th day All but $148 a day $0 Up to $148 a day
101st day and after $0 $0 All costs
BLOODFirst three pints $0 Three pints $0
Additional amounts 100% $0 $0
HOSPICECAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
RI81077RD 7
PLAN AMEDICARE(PARTB)-MEDICALSERVICES-PERCALENDARYEAR* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays YouPayMEDICALEXPENSES–IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 $0 All costs
BLOODFirst three pints $0 All costs $0
Next $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
CLINICALLABORATORYSERVICES– TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
Medicare Parts A & BServices Medicare Pays Plan Pays YouPay
HOMEHEALTHCAREMEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipmentFirst $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
8 RI81077RD
PLAN AInnovative Benefits
Services Medicare Pays Plan Pays YouPayDENTAL
In-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 100% $0
Oral Cancer Screening, up to 1 per calendar year
$0 100% $0
Extractions (Unlimited) $0 75% 25%
Restorative (fillings), up to 1 per calendar year
$0 50% 50%
Out-of-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 50% 50%
Oral Cancer Screening, up to 1 per calendar year
$0 50% 50%
Extractions (Unlimited) $0 50% 50%
Restorative (fillings), up to 1 per calendar year
$0 45% 55%
VISION
Routine examination with dilation, once every 12 months
$0 100%* $0
Eye glasses or contact lenses - conventional and disposable
$0 $100 allowance Remaining Balance
* up to $75 allowance provided for Out-of-Network
RI81077RD 9
PLAN FMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays YouPayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,184 $1,184 (Part A deductible)
$0
61st through 90th day All but $296 a day $296 a day $0
91st day and after: while using 60 lifetime reserve days once lifetime reserve days are used:
- additional 365 days
All but $592 a day
$0
$592 a day
100% of Medicare eligible expenses
$0
$0**
- beyond the additional 365 days $0 $0 All costs
SKILLEDNURSINGFACILITYCARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st through 100th day All but $148 a day Up to $148 a day $0
101st day and after $0 $0 All costs
BLOODFirst three pints $0 Three pints $0
Additional amounts 100% $0 $0
HOSPICECAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
10 RI81077RD
PLAN FMEDICARE(PARTB)-MEDICALSERVICES-PERCALENDARYEAR* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays YouPayMEDICALEXPENSES–IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 100% $0
BLOODFirst three pints $0 All costs $0
Next $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
CLINICALLABORATORYSERVICES– TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
Medicare Parts A & BServices Medicare Pays Plan Pays YouPay
HOMEHEALTHCAREMEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipmentFirst $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
RI81077RD 11
PLAN FOtherBenefits-NotCoveredByMedicare
Services Medicare Pays Plan Pays YouPayFOREIGNTRAVEL–NOTCOVEREDBYMEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside of the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
Innovative BenefitsServices Medicare Pays Plan Pays YouPay
DENTAL
In-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 100% $0
Oral Cancer Screening, up to 1 per calendar year
$0 100% $0
Extractions (Unlimited) $0 75% 25%
Restorative (fillings), up to 1 per calendar year
$0 50% 50%
Out-of-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 50% 50%
Oral Cancer Screening, up to 1 per calendar year
$0 50% 50%
Extractions (Unlimited) $0 50% 50%
Restorative (fillings), up to 1 per calendar year
$0 45% 55%
12 RI81077RD
Innovative Benefits (continued)
Services Medicare Pays Plan Pays YouPayVISION
Routine examination with dilation, once every 12 months
$0 100%* $0
Eye glasses or contact lenses - conventional and disposable
$0 $100 allowance Remaining Balance
* up to $75 allowance provided for Out-of-Network
PLAN F
RI81077RD 13
HIGHDEDUCTIBLEPLANFMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare Pays
AfterYouPay $2,110
Deductible,** Plan Pays
In Addition To$2,110
Deductible,** YouPay
HOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,184 $1,184 (Part A deductible)
$0
61st through 90th day All but $296 a day $296 a day $0
91st day and after: while using 60 lifetime reserve days once lifetime reserve days are used:
- additional 365 days
All but $592 a day
$0
$592 a day
100% of Medicare eligible expenses
$0
$0***
- beyond the additional 365 days $0 $0 All costs
SKILLEDNURSINGFACILITYCARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st through 100th day All but $148 a day Up to $148 a day $0
101st day and after $0 $0 All costs
***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
14 RI81077RD
HIGHDEDUCTIBLEPLANFMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD(Continued)
** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare Pays
AfterYouPay $2,110
Deductible,** Plan Pays
In Addition To$2,110
Deductible,** YouPay
BLOODFirst three pints $0 Three pints $0
Additional amounts 100% $0 $0
HOSPICECAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
RI81077RD 15
HIGHDEDUCTIBLEPLANFMEDICARE(PARTB)-MEDICALSERVICES-PERCALENDARYEAR* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare Pays
AfterYouPay $2,110
Deductible,** Plan Pays
In Addition To$2,110
Deductible,** YouPay
MEDICALEXPENSES–IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
Generally 80% Generally 20% $0
PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 100% $0
BLOODFirst three pints $0 All costs $0
Next $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
CLINICALLABORATORYSERVICES– TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
16 RI81077RD
HIGHDEDUCTIBLEPLANFMEDICARE(PARTSAANDB)* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
** This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits from the high deductible Plan F will not begin until out-of-pocket expenses are $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.
Services Medicare Pays
AfterYouPay $2,110
Deductible,** Plan Pays
In Addition To$2,110
Deductible,** YouPay
HOMEHEALTHCAREMEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipmentFirst $147 of Medicare-approved amounts*
$0 $147 (Part B deductible)
$0
Remainder of Medicare-approved amounts
80% 20% $0
OtherBenefits-NotCoveredByMedicare
Services Medicare Pays
AfterYouPay $2,110
Deductible,** Plan Pays
In Addition To$2,110
Deductible,** YouPay
FOREIGNTRAVEL–NOTCOVEREDBYMEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside of the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
RI81077RD 17
Innovative BenefitsDental and vision coverage is not subject to the high deductible for this Plan.
Services Medicare Pays Plan Pays YouPayDENTAL
In-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 100% $0
Oral Cancer Screening, up to 1 per calendar year
$0 100% $0
Extractions (Unlimited) $0 75% 25%
Restorative (fillings), up to 1 per calendar year
$0 50% 50%
Out-of-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 50% 50%
Oral Cancer Screening, up to 1 per calendar year
$0 50% 50%
Extractions (Unlimited) $0 50% 50%
Restorative (fillings), up to 1 per calendar year
$0 45% 55%
VISION
Routine examination with dilation, once every 12 months
$0 100%* $0
Eye glasses or contact lenses - conventional and disposable
$0 $100 allowance Remaining Balance
* up to $75 allowance provided for Out-of-Network
HIGHDEDUCTIBLEPLANF
18 RI81077RD
PLAN K* You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,800 each calendar year. The amounts that count toward your annual limit are noted with diamonds (u) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. However,thislimitdoesNOTincludechargesfromyourproviderthatexceedMedicare-approvedamounts(thesearecalled“ExcessCharges”)andyou will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
MEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD** A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you
have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays YouPay*HOSPITALIZATION**Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,184 $592 (50% of Part A deductible)
$592 (50% of Part A deductible)u
61st through 90th day All but $296 a day $296 a day $0
91st day and after: while using 60 lifetime reserve days once lifetime reserve days are used:
- additional 365 days
All but $592 a day
$0
$592 a day
100% of Medicare eligible expenses
$0
$0***
- beyond the additional 365 days $0 $0 All costs
SKILLEDNURSINGFACILITYCARE**You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st through 100th day All but $148 a day Up to $74 a day Up to $74 a dayu
101st day and after $0 $0 All costs
*** NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
RI81077RD 19
PLAN KMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD (Continued)
Services Medicare Pays Plan Pays YouPay*BLOODFirst three pints $0 50% 50%u
Additional amounts 100% $0 $0
HOSPICECAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
50% of coinsurance or copayments
50% of coinsurance or copaymentsu
20 RI81077RD
PLAN KMEDICARE(PARTB)-MEDICALSERVICES-PERCALENDARYEAR**** Once you have been billed $147 of Medicare-approved amounts for covered services (which are
noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays YouPay*MEDICALEXPENSES–IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $147 of Medicare-approved amounts****
$0 $0 $147 (Part B deductible)****u
Preventive Benefits for Medicare covered services
Generally 80% ormore of Medicare approved amounts
Remainder of Medicare approved amounts
All costs above Medicare approved amounts
Remainder of Medicare-approved amounts
Generally 80% Generally 10% Generally 10%u
PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 $0 All costs (and
they do not count toward annual out-of-pocket limit of $4,800)*
BLOODFirst three pints $0 50% 50%u
Next $147 of Medicare-approved amounts****
$0 $0 $147 (Part B deductible)****u
Remainder of Medicare-approved amounts
Generally 80% Generally 10% Generally 10%u
CLINICALLABORATORYSERVICES– TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
* This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,800 per year. However,thislimitdoesNOTincludechargesfromyourproviderthatexceedMedicare-approvedamounts(thesearecalled"ExcessCharges")andyouwillberesponsibleforpayingthis difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
RI81077RD 21
PLAN KMedicare Parts A & B
Services Medicare Pays Plan Pays YouPay*HOMEHEALTHCAREMEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipmentFirst $147 of Medicare-approved amounts*****
$0 $0 $147 (Part B deductible)u
Remainder of Medicare-approved amounts
80% 10% 10%u
***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.
Innovative BenefitsServices Medicare Pays Plan Pays YouPay
DENTAL
In-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 100% $0
Oral Cancer Screening, up to 1 per calendar year
$0 100% $0
Extractions (Unlimited) $0 75% 25%
Restorative (fillings), up to 1 per calendar year
$0 50% 50%
Out-of-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 50% 50%
Oral Cancer Screening, up to 1 per calendar year
$0 50% 50%
Extractions (Unlimited) $0 50% 50%
Restorative (fillings), up to 1 per calendar year
$0 45% 55%
22 RI81077RD
Innovative Benefits (continued)
Services Medicare Pays Plan Pays YouPayVISION
Routine examination with dilation, once every 12 months
$0 100%* $0
Eye glasses or contact lenses - conventional and disposable
$0 $100 allowance Remaining Balance
* up to $75 allowance provided for Out-of-Network
PLAN K
RI81077RD 23
PLAN NMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan Pays YouPayHOSPITALIZATION*Semiprivate room and board, general nursing and miscellaneous services and supplies
First 60 days All but $1,184 $1,184 (Part A deductible)
$0
61st through 90th day All but $296 a day $296 a day $0
91st day and after: while using 60 lifetime reserve days once lifetime reserve days are used:
- additional 365 days
All but $592 a day
$0
$592 a day
100% of Medicare eligible expenses
$0
$0**
- beyond the additional 365 days $0 $0 All costs
SKILLEDNURSINGFACILITYCARE*You must meet Medicare’s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital
First 20 days All approved amounts
$0 $0
21st through 100th day All but $148 a day Up to $148 a day $0
101st day and after $0 $0 All costs
BLOODFirst three pints $0 Three pints $0
Additional amounts 100% $0 $0
HOSPICECAREYou must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care
Medicare copayment/coinsurance
$0
**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
24 RI81077RD
PLAN NMEDICARE(PARTB)-MEDICALSERVICES-PERCALENDARYEAR* Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
Services Medicare Pays Plan Pays YouPayMEDICALEXPENSES–IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment
First $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.
PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 $0 All costs
BLOODFirst three pints $0 All costs $0
Next $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
CLINICALLABORATORYSERVICES– TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0
RI81077RD 25
PLAN NMedicare Parts A & B
Services Medicare Pays Plan Pays YouPayHOMEHEALTHCAREMEDICARE-APPROVED SERVICES
Medically necessary skilled care services and medical supplies
100% $0 $0
Durable medical equipmentFirst $147 of Medicare-approved amounts*
$0 $0 $147 (Part B deductible)
Remainder of Medicare-approved amounts
80% 20% $0
OtherBenefits-NotCoveredByMedicareServices Medicare Pays Plan Pays YouPay
FOREIGNTRAVEL–NOTCOVEREDBYMEDICARE
Medically necessary emergency care services beginning during the first 60 days of each trip outside of the USA
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime maximum benefit of $50,000
20% and amounts over the $50,000 lifetime maximum
Innovative BenefitsServices Medicare Pays Plan Pays YouPay
DENTAL
In-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 100% $0
Oral Cancer Screening, up to 1 per calendar year
$0 100% $0
Extractions (Unlimited) $0 75% 25%
Restorative (fillings), up to 1 per calendar year
$0 50% 50%
26 RI81077RD
PLAN NInnovative Benefits (continued)
Services Medicare Pays Plan Pays YouPayOut-of-Network
Preventive Services: - Cleaning, up to 2 per calendar year- Oral Exams, up to 2 per calendar year- Dental X-Ray, up to 1 per calendar year
$0 50% 50%
Oral Cancer Screening, up to 1 per calendar year
$0 50% 50%
Extractions (Unlimited) $0 50% 50%
Restorative (fillings), up to 1 per calendar year
$0 45% 55%
VISION
Routine examination with dilation, once every 12 months
$0 100%* $0
Eye glasses or contact lenses - conventional and disposable
$0 $100 allowance Remaining Balance
* up to $75 allowance provided for Out-of-Network
RI81077RD 27
Notes____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
28 RI81077RD
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RI81077RD Insured by Humana Insurance Company 113
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