Humana Gold Choice H2944-197 (PFFS)
Humana Gold Choice H2944-197 (PFFS) H2944-197 Plan Details
Humana Gold Choice H2944-197 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2944-197.
$19.00
Monthly Premium
Humana Gold Choice H2944-197 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2944-197.
Humana Gold Choice H2944-197 (PFFS) H2944-197 Plan Details
Humana Gold Choice H2944-197 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2944-197.
$19.00
Monthly Premium
Kansas Counties Served
Barber
Barton
Brown
Chase
Cheyenne
Clark
Clay
Cloud
Coffey
Comanche
Decatur
Edwards
Ellis
Ellsworth
Finney
Ford
Gove
Graham
Grant
Gray
Greeley
Hamilton
Haskell
Hodgeman
Jewell
Kearny
Kiowa
Lane
Lincoln
Logan
Lyon
Marshall
Meade
Mitchell
Morton
Nemaha
Ness
Norton
Osborne
Pawnee
Phillips
Pratt
Rawlins
Republic
Rice
Riley
Rooks
Rush
Russell
Saline
Seward
Sheridan
Sherman
Smith
Stafford
Stanton
Stevens
Thomas
Trego
Wallace
Washington
Wichita
Missouri Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $10.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $360.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Out-of-Network: Copayment for Acute Hospital Services per Stay $0.00 |
| Urgent Care | Copayment for Urgent Care $10.00 to $40.00 Cost share amount will apply based on the setting where the service is received: In-Network $10.00 PCP $40.00 Specialist $30.00 Urgent Care Center Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $90.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $265.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% |
Health Care Services and Medical Supplies
Humana Gold Choice H2944-197 (PFFS) 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-Network: Copayment for Medicare-covered Chiropractic Services $10.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00 Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 19% Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 19% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $40.00 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 to $30.00 Coinsurance for Medicare-covered Lab Services 25% Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $40.00 to $270.00 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% to 30% Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Copayment for Medicare-covered X-Ray Services $10.00 to $40.00 Coinsurance for Medicare-covered X-Ray Services 30% Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Lab Services $0.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $318.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $0.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $40.00 to $360.00 Coinsurance for Medicare Covered Outpatient Hospital Services 20% Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $310.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Coinsurance for Medicare-covered Individual Sessions 20% Copayment for Medicare-covered Group Sessions $40.00 Coinsurance for Medicare-covered Group Sessions 20% |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50% Maximum Plan Benefit of $50.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 Out-of-Network: Copayment for Skilled Nursing Facility Services per Stay $0.00 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $40.00 Eyewear: Copayment for Medicare-Covered Benefits $0.00 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40.00 |
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 | 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:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
