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Savannah River Mission Completion Low Plan
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$179.83
Monthly Premium
Savannah River Mission Completion Low Plan is a plan offered by Humana Inc.
Plan ID: H5216-805
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Savannah River Mission Completion Low Plan - H5216-805 by Humana Inc. as well as other Medicare Advantage plans available in your area.
$179.83
Monthly Premium
Rhode Island Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $2000 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | In or Out of Network: $0 copayment |
| Specialty Doctor Visit | In or Out of Network: $20 copayment |
| Inpatient Hospital Care | In or Out of Network: $150 copayment per admission |
| Urgent Care | In or Out of Network: $0 - $20 copayment |
| Emergency Room Visit | Out of Network: Worldwide Coverage 20% coinsurance, $100 deductible per year, $25000 maximum benefit per year Or 60 consecutive days, whichever is reached first. Limited to emergency Medicare-covered services. |
| Ambulance Transportation | In or Out of Network: $75 copayment per date of service, Limited to Medicare-covered transportation. |
Health Care Services and Medical Supplies
Savannah River Mission Completion Low Plan covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In or Out of Network: Chiropractic Services (Medicare Covered) $20 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 - $75 copayment Medicare-Covered diagnostic procedures and tests Medicare-Covered diagnostic procedures and tests: In or Out of Network: $0 - $75 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 - $75 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: $20 - $50 copayment Medicare-covered X-rays Medicare-covered X-rays: In or Out of Network: $0 - $75 copayment |
| Home Health Care | In or Out of Network: $0 copayment, Excludes Personal Home Care. |
| Mental Health Inpatient Care | In or Out of Network: $150 copayment per admission, 190 day lifetime limit in a psychiatric facility. |
| Mental Health Outpatient Care | In or Out of Network: $0 - $40 copayment |
| Outpatient Services / Surgery | Ambulatory Surgical Center Ambulatory Surgical Center: In or Out of Network: $0 - $50 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 - $75 copayment |
| Outpatient Substance Abuse Care | Opioid Treatment: In or Out of Network: $20 - $40 copayment Outpatient Substance Abuse: In or Out of Network: $0 - $40 copayment |
| Over-the-counter (OTC) Items | In Network: $25 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) $20 copayment |
| Skilled Nursing Facility Care | In or Out of Network: $0 copayment per day for days 1-20, $25 copayment per day for days 21-100, Plan pays $0 after 100 days. |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In or Out of Network: Dental Services (Medicare Covered) $20 copayment Dental Services (Routine) 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam, intraoral x-rays up to 1 per year. 0% coinsurance for amalgam and/or composite filling, fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia (inhalation of nitrous oxide/analgesia, anxiolysis) with covered service up to as needed with covered codes per year. 0% coinsurance for simple or surgical extraction up to unlimited per year. $500 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 from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out of Network: Vision Services Vision Services: Vision Services (Medicare Covered) $20 copayment Vision Services (Routine) $175 combined maximum benefit coverage amount per year for routine exam (includes refraction). $0 copayment for routine exam (includes refraction) up to 1 per year. $100 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). Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. The approved provider, EyeMed Vision, must be used in order to obtain benefits. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In or Out of Network: Hearing Services (Medicare Covered) $20 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. $299 copayment for each Advanced level hearing aid up to 1 per ear per year. $599 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 from in-network providers.
| Coverage | Cost |
|---|---|
| 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 |