€¦ · the same benefits as Plan F after one has paid a calendar year $2,110 deductible. Benefits...

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*



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*



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


$0 50% 50%


$0 50% 50%



$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.


First 60 days All but $1,184 $1,184 (Part A deductible)

$0




All but $592 a day

$0

$592 a day


$0

$0**




$0 $0

21st through 100th day All but $148 a day Up to $148 a day $0







$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.



$0 $147 (Part B deductible)

$0



PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 100% $0




$0


80% 20% $0


Medicare Parts A & BServices Medicare Pays Plan Pays YouPay



100% $0 $0



$0


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


$0 100% $0


$0 100% $0



$0 50% 50%

Out-of-Network


$0 50% 50%


$0 50% 50%



$0 45% 55%

12 RI81077RD

Innovative Benefits (continued)

Services Medicare Pays Plan Pays YouPayVISION


$0 100%* $0




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


$0




All but $592 a day

$0

$592 a day


$0

$0***




$0 $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.

14 RI81077RD

HIGHDEDUCTIBLEPLANFMEDICARE(PARTA)-HOSPITALSERVICES-PERBENEFITPERIOD(Continued)



AfterYouPay $2,110









$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.



AfterYouPay $2,110




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



$0



PARTBEXCESSCHARGES (above Medicare-approved amounts) $0 100% $0




$0


80% 20% $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.



AfterYouPay $2,110






100% $0 $0



$0


80% 20% $0

OtherBenefits-NotCoveredByMedicare


AfterYouPay $2,110




FOREIGNTRAVEL–NOTCOVEREDBYMEDICARE





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


$0 100% $0


$0 100% $0



$0 50% 50%

Out-of-Network


$0 50% 50%


$0 50% 50%



$0 45% 55%

VISION


$0 100%* $0




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




All but $592 a day

$0

$592 a day


$0

$0***


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


$0 $0

21st through 100th day All but $148 a day Up to $74 a day Up to $74 a dayu


*** 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




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


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


Generally 80% Generally 10% Generally 10%u


* 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


100% $0 $0

Durable medical equipmentFirst $147 of Medicare-approved amounts*****

$0 $0 $147 (Part B deductible)u


80% 10% 10%u

***** Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.


DENTAL

In-Network


$0 100% $0


$0 100% $0



$0 50% 50%

Out-of-Network


$0 50% 50%


$0 50% 50%



$0 45% 55%

22 RI81077RD

Innovative Benefits (continued)

Services Medicare Pays Plan Pays YouPayVISION


$0 100%* $0




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.



$0




All but $592 a day

$0

$592 a day


$0

$0**




$0 $0








$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.





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





80% 20% $0


RI81077RD 25

PLAN NMedicare Parts A & B

Services Medicare Pays Plan Pays YouPayHOMEHEALTHCAREMEDICARE-APPROVED SERVICES


100% $0 $0




80% 20% $0

OtherBenefits-NotCoveredByMedicareServices Medicare Pays Plan Pays YouPay

FOREIGNTRAVEL–NOTCOVEREDBYMEDICARE






DENTAL

In-Network


$0 100% $0


$0 100% $0



$0 50% 50%

26 RI81077RD

PLAN NInnovative Benefits (continued)

Services Medicare Pays Plan Pays YouPayOut-of-Network


$0 50% 50%


$0 50% 50%



$0 45% 55%

VISION


$0 100%* $0




RI81077RD 27

Notes____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

28 RI81077RD

Notes____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RI81077RD Insured by Humana Insurance Company 113

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