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Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP)

Humana Inc.
Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) H4461-038 Plan Details
5 out of 5 stars

Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H4461-038.

$0.00
Monthly Premium

Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H4461-038.

Humana Inc.
Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) H4461-038 Plan Details
5 out of 5 stars

Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H4461-038.

$0.00
Monthly Premium

Tennessee Counties Served

Anderson Bedford Benton Bledsoe Cannon Blount Bradley Campbell Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Davidson Decatur Dekalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury Mcminn Mcnairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $0
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 $0.00
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 $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $95.00
Emergency Room Visit
Copayment for Emergency Care $0.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $95.00
Copayment for Worldwide Emergency Transportation $95.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00

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

Health Care Services and Medical Supplies

Humana Gold Plus SNP-DE H4461-038 (HMO D-SNP) 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 $0.00
Copayment for Routine Care $0.00
  • Maximum 12 Routine Care every year
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
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
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:
Copayment for Medicare-covered Durable Medical Equipment $0.00
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
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
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:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
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 $0.00
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 $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00
  • Maximum 6 visits every year
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
$0.00 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:

Preventive Dental:
Maximum Plan Allowance of $3000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Maximum Plan Allowance of $3000.00 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
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 $400.00 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 $0.00
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 $0.00
  • Maximum 2 Hearing Aids every three years

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
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