Humana DaVita Kidney Care (PPO C-SNP)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $35%

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit $30%

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $2241
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Coinsurance for Urgent Care 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $0

In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services $20%

Air Ambulance:
Copayment for Air Ambulance Services $335
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 20%
In-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%
Prior Authorization Required for Chiropractic Services

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% to 50%
Copayment for Medicare Covered Lab Services $0
Copayment for Medicare Covered Diagnostic Radiological Services $0
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20% to 50%
20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC20% OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $2091
Prior Authorization Required for Psychiatric Hospital Services

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $35
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH20% Surgery Svcs - OPH20% Wound Care - OPH

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC20% Surgery Svcs - ASC

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 35% to 50%
Coinsurance for Medicare Covered Group Sessions 35% to 50%
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Prior Authorization Required for Outpatient Substance Abuse Services

In-Network:
$150 monthly allowance on a prepaid spending card. All plan members receive this amount to buy approved over the counter (OTC) health and wellness products at participating retailers or through the plan’s approved OTC mail order vendor. Plus, members may also use this money for eligible groceries, utilities, rent, and more if they have certain qualifying chronic condition(s) and meet other program criteria. Any unused amount rolls over each month and expires at the end of the plan year or upon disenrollment, whichever occurs first.

Out-of-Network:
95% coinsurance.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
In-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 20%
Prior Authorization Required for Podiatry Services

In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

In-Network:
Plan covers up to $1500 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.

Out-of-Network:
Plan covers up to $1500 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 50%
$0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 30%

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots
• Flu shots
• Hepatitis B shots
• Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit