Humana Gold Choice H8145-120 (PFFS)
Humana Gold Choice H8145-120 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-120.
$31.00
Monthly Premium
Humana Gold Choice H8145-120 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-120.
Arkansas Counties Served
Arkansas
Ashley
Benton
Baxter
Carroll
Cleburne
Conway
Craighead
Crawford
Crittenden
Cross
Dallas
Faulkner
Franklin
Fulton
Garland
Greene
Hot Spring
Independence
Jackson
Jefferson
Johnson
Lawrence
Lee
Logan
Mccurtain
Montgomery
Pope
Prairie
Pulaski
Randolph
Saline
Scott
Sebastian
Stone
Union
Van Buren
Washington
Kansas Counties Served
Missouri Counties Served
Atchison
Barry
Barton
Benton
Boone
Butler
Callaway
Camden
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clay
Cole
Crawford
Dade
Dallas
Dekalb
Dent
Douglas
Gasconade
Gentry
Greene
Grundy
Henry
Hickory
Holt
Iron
Jackson
Jasper
Jefferson
Laclede
Lawrence
Macon
Madison
Mcdonald
Mercer
Miller
Mississippi
Montgomery
New Madrid
Newton
Nodaway
Ozark
Pemiscot
Perry
Phelps
Pike
Platte
Polk
Pulaski
Reynolds
Ripley
Saint Charles
Saint Clair
Saint Louis
Saint Louis City
Stoddard
Stone
Taney
Vernon
Washington
Worth
Wright
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 $10.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 40% |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% |
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: Coinsurance for Acute Hospital Services per Stay 40% |
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% Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $265.00 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Humana Gold Choice H8145-120 (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 Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 40% |
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% to 40% |
Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
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 $0.00 to $360.00 Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $10.00 to $40.00 Coinsurance for Medicare-covered X-Ray Services 20% Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% |
Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Out-of-Network: Coinsurance for Medicare Covered Home Health 40% |
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: Coinsurance for Psychiatric Hospital Services per Stay 40% |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $40.00 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 Coinsurance for Ambulatory Surgical Center Services 20% Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
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% Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 40% |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 40% |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $178.00 per day for days 21 to 100 Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 40% |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 40% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00 |
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 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $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 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $399.00 to $699.00
Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 40% Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $399.00 to $699.00 |
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 Coinsurance for Medicare Covered Medicare-covered Preventive Services 40% |