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Savannah River Mission Completion High - H5216-805-604
$265.09
Monthly Premium
Savannah River Mission Completion High is a Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-805-604
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$265.09
Monthly Premium
Mississippi Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Mississippi Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $265.09 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $400.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In or Out of Network: $0 copayment |
| Specialty doctor visit | In or Out of Network: $0 copayment |
| Inpatient hospital care | In or Out of Network: $100 copayment per admission |
| Urgent care | In or Out of Network: $0 copayment |
| Emergency room visit | In or Out of Network: $50 copayment, waived if admitted within 24 hours |
| Ambulance transportation | In or Out of Network: $25 copayment per date of service, Limited to Medicare-covered transportation. |
Health Care Services and Medical Supplies
Savannah River Mission Completion High covers a range of additional benefits. Learn more about Savannah River Mission Completion High benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In or Out of Network: Chiropractic Services (Medicare Covered) $0 copayment |
| Diabetes supplies, training, nutrition therapy and monitoring | Diabetes Self-Management Services Diabetes Self-Management Services: In or Out of Network: $0 copayment Diabetes Supplies and Services Diabetes Supplies and Services: In or Out of Network: $0 copayment |
| Durable medical equipment (DME) | In or Out of Network: $0 copayment |
| Diagnostic tests, lab and radiology services, and X-rays | Diagnostic Tests, Lab and Radiology Services, and X-Rays Diagnostic Tests, Lab and Radiology Services, and X-Rays: In or Out of Network: $0 - $25 copayment Medicare-Covered diagnostic procedures and tests Medicare-Covered diagnostic procedures and tests: In or Out of Network: $0 - $25 copayment Medicare-covered diagnostic radiology services (not including x-rays) Medicare-covered diagnostic radiology services (not including x-rays): In or Out of Network: $0 - $25 copayment Medicare-covered lab services Medicare-covered lab services: In or Out of Network: $0 copayment Medicare-covered therapeutic radiology services Medicare-covered therapeutic radiology services: In or Out of Network: $0 copayment Medicare-covered X-rays Medicare-covered X-rays: In or Out of Network: $0 - $25 copayment |
| Home health care | In or Out of Network: $0 copayment, Excludes Personal Home Care. |
| Mental health inpatient care | In or Out of Network: $100 copayment per admission, 190 day lifetime limit in a psychiatric facility. |
| Mental health outpatient care | In or Out of Network: $0 copayment |
| Outpatient services/surgery | Ambulatory Surgical Center Ambulatory Surgical Center: In or Out of Network: $0 copayment Observation Services Observation Services: In or Out of Network: $0 copayment, waived if admitted within 24 hours Outpatient Services/Surgery Outpatient Services/Surgery: In or Out of Network: $0 - $25 copayment |
| Outpatient substance abuse care | Opioid Treatment: In or Out of Network: $0 copayment Outpatient Substance Abuse: In or Out of Network: $0 copayment |
| Over-the-counter items | In Network: $50 maximum benefit coverage amount per quarter (3 months) for select over-the-counter health and wellness products. Unused amount expires at the end of the quarter. The approved provider, CenterWell, must be used in order to obtain benefits. |
| Podiatry services | In or Out of Network: Podiatry Services (Medicare Covered) $0 copayment |
| Skilled Nursing Facility (SNF) care | In or Out of Network: $0 copayment per day for days 1-100, Plan pays $0 after 100 days. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In or Out of Network: Dental Services (Medicare Covered) $0 copayment Dental Services (Routine) 0% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. 0% coinsurance for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. 0% coinsurance for complete dentures, partial dentures up to 1 set(s) every 5 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime. 0% coinsurance for bitewing x-rays up to 1 set(s) per year. 0% coinsurance for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, intraoral x-rays, root canal or retreatment, tissue conditioning up to 1 per year. 0% coinsurance for amalgam and/or composite filling, crown, emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for general anesthesia (nitrous oxide, anxiolysis, intravenous-conscious-sedation/analgesia), simple or surgical extraction up to unlimited per year. $1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. The approved provider, HumanaDental, must be used in order to obtain benefits. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Medicare-covered Eyewear Medicare-covered Eyewear: In or Out of Network: $0 copayment, For eyeglasses and contacts following cataract surgery. Vision Services Vision Services: Vision Services (Medicare Covered) $0 copayment Vision Services (Routine) $0 copayment for routine exam (includes refraction) up to 1 per year. $150 combined maximum benefit coverage amount per year for contact lenses, eyeglasses (lenses and frames), including lens options such as ultraviolet protection and scratch resistant coating, fitting for eyeglasses (lenses and frames). The approved provider, EyeMed Vision, must be used in order to obtain benefits. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In or Out of Network: Hearing Services (Medicare Covered) $0 copayment Hearing Services (Routine) $0 copayment for routine hearing exams up to 1 per year. $0 copayment for follow-up provider visits up to unlimited per year. $99 copayment for each Advanced level hearing aid up to 1 per ear per year. $399 copayment for each Premium level hearing aid up to 1 per ear per year. Note: Includes 80 batteries per aid and 3 year warranty. Unlimited follow-up provider visits during first year following TruHearing hearing aid purchase. The approved provider, TruHearing, must be used in order to obtain benefits. |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Glaucoma Screening Glaucoma Screening: In or Out of Network: $0 copayment Preventive Services Preventive Services: In or Out of Network: $0 copayment |
When reviewing Mississippi Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Mississippi that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Mississippi Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.