Humana Dual Select H7284-010 (PPO D-SNP)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $0% or$ 40%

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Prior Authorization Required for Doctor Specialty Visit

Out-of-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0 or $2500

Urgent Care:
Copayment for Urgent Care $0 or $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0 or $40

Emergency Care:
Copayment for Emergency Care $0 or $130
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 $0 or $130
Copayment for Worldwide Emergency Transportation $0

In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services $0% or$ 20%

Air Ambulance:
Coinsurance for Air Ambulance Services $0% or$ 20%
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 0% or 40%
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services

In-Network:

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

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% or 50%
20% DME - DME Prov20% DME - Pharmacy$0 DME-Oxygen System - DME Prov

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0 or $40
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0 or 40%
Copayment for Medicare Covered Lab Services $0 or 0 to $40
Coinsurance for Medicare Covered Lab Services 0 or 40%
Copayment for Medicare Covered Diagnostic Radiological Services $0 or 0
Coinsurance for Medicare Covered Diagnostic Radiological Services 0 or 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 0% or 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0 or $40
Coinsurance for Medicare Covered Outpatient X-Ray Services 0 or 40%
20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$0 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH$0 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0 or $1000
Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:

Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 0% or 40%
Coinsurance for Medicare Covered Group Sessions 0% or 40%

In-Network:

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

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 0% or 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 or 0
Coinsurance for Ambulatory Surgical Center Services 0 or 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 0% or 40%
Coinsurance for Medicare Covered Group Sessions 0% or 40%
$35 OP Substance Abuse Care - OPH$0 OP Substance Abuse Care - SPC
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0 to $35
Copayment for Medicare-covered Group Sessions $0 to $35
Prior Authorization Required for Outpatient Substance Abuse Services
$35 OP Substance Abuse Care - OPH$0 OP Substance Abuse Care - SPC

In-Network:
$50 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 0% or 40%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Copayment for Routine Foot Care $0

• Maximum 12 visits every year

Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$210 per day for days 21 to 100

In-Network:
Plan covers up to $1250 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 $1250 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.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Maximum Plan Benefit of $300 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $100 less than the PLUS network.

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 0% or 40%

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0