Humana Gold Plus H5178-001 (HMO)

Humana Inc.
Humana Gold Plus H5178-001 (HMO) H5178-001 Plan Details
Plan too new to be measured

Humana Gold Plus H5178-001 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5178-001.

$126.00
Monthly Premium

Humana Gold Plus H5178-001 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5178-001.

Humana Inc.
Humana Gold Plus H5178-001 (HMO) H5178-001 Plan Details
Plan too new to be measured

Humana Gold Plus H5178-001 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5178-001.

$126.00
Monthly Premium

South Carolina Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $390
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Coinsurance for Primary Care Office Visit 20%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 20%
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $1860.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Coinsurance for Urgent Care 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Humana Gold Plus H5178-001 (HMO) 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:
Coinsurance for Medicare-covered Chiropractic Services 20%
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 10%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
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
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0.00
Coinsurance for Medicare-covered Lab Services 20%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Coinsurance for Medicare-covered X-Ray Services 20%
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1660.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Coinsurance for Medicare-Covered Podiatry Services 20%
Prior Authorization Required for Podiatry Services
Prior authorization required
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
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Prior Authorization Required for Comprehensive Dental
Prior authorization required

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
Coinsurance for Medicare Covered Benefits 20%
Prior Authorization Required for Eye Exams

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Prior Authorization Required for Eyewear
Prior authorization required

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 20%
Prior Authorization Required for Hearing Exams
Prior authorization required

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit