Humana Gold Plus H6622-057 (HMO)

Humana Inc.
Humana Gold Plus H6622-057 (HMO) H6622-057 Plan Details
4 out of 5 stars

Humana Gold Plus H6622-057 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H6622-057.

$0.00
Monthly Premium

Humana Gold Plus H6622-057 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H6622-057.

Humana Inc.
Humana Gold Plus H6622-057 (HMO) H6622-057 Plan Details
4 out of 5 stars

Humana Gold Plus H6622-057 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H6622-057.

$0.00
Monthly Premium

North Carolina Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4400
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 $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$345.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00 to $25.00

Cost share amount will apply based on the setting where the service is received: In-Network $0.00 PCP $25.00 Specialist $15.00 Urgent Care Center

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:
Copayment for Ground Ambulance Services $290.00

Air Ambulance:
Copayment for Air Ambulance Services $290.00

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

Health Care Services and Medical Supplies

Humana Gold Plus H6622-057 (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:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
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
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 20%
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 to $75.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $25.00 to $275.00
Copayment for Medicare-covered Therapeutic Radiological Services $25.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $90.00
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:
$345.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25.00
Copayment for Medicare-covered Group Sessions $25.00
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 $25.00 to $345.00
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 $295.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25.00 to $75.00
Copayment for Medicare-covered Group Sessions $25.00 to $75.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
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 three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25.00
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
$188.00 per day for days 21 to 44
$0.00 per day for days 45 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:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 4 visits (Please see Evidence of Coverage for details)
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 6 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $25.00
Copayment for Restorative Services $25.00
  • Maximum 2 visits every year
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
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 to $25.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear
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:
Copayment for Medicare Covered Benefits $25.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
$699 copayment per ear per year for advanced level hearing aid purchase or $999 copayment per ear per year for premium level hearing aid purchase.
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