Humana Gold Choice H2944-197 (PFFS)
Humana Gold Choice H2944-197 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H2944-197.
Humana Gold Choice H2944-197 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H2944-197.
Kansas 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 | $4660 |
Catastrophic Coverage Limit | $7,400 |
Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 |
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 $30.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00 |
Emergency Room Visit | Copayment for Emergency Care $95.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Copayment for Worldwide Emergency Transportation $95.00 |
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 $30.00 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 $0.00 to $270.00 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Copayment for Medicare-covered Therapeutic Radiological Services $30.00 to $40.00 Copayment for Medicare-covered X-Ray Services $0.00 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 $30.00 Copayment for Medicare-covered Group Sessions $30.00 |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 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 $0.00 to $310.00 |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Coinsurance for Medicare-covered Individual Sessions 20% Copayment for Medicare-covered Group Sessions $30.00 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 $30.00 |
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 $30.00 |
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 $30.00 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 $30.00 |
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 |