HumanaChoice H5216-223 (PPO)
HumanaChoice H5216-223 (PPO) H5216-223 Plan Details
HumanaChoice H5216-223 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5216-223.
$28.00
Monthly Premium
HumanaChoice H5216-223 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5216-223.
HumanaChoice H5216-223 (PPO) H5216-223 Plan Details
HumanaChoice H5216-223 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H5216-223.
$28.00
Monthly Premium
Colorado Counties Served
Adams
El Paso
Alamosa
Arapahoe
Bent
Boulder
Broomfield
Chaffee
Clear Creek
Colfax
Conejos
Costilla
Crowley
Custer
Delta
Denver
Deuel
Dolores
Douglas
Elbert
Fremont
Gilpin
Gunnison
Hinsdale
Huerfano
Jackson
Jefferson
La Plata
Lake
Larimer
Las Animas
Lincoln
Logan
Mesa
Mineral
Montezuma
Montrose
Morgan
Otero
Ouray
Park
Pueblo
Rio Blanco
Rio Grande
Saguache
San Miguel
Summit
Teller
Washington
Weld
New Mexico Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4900 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 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $30.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $60.00 Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $250.00 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 Out-of-Network: $500.00 per day for days 1 to 20 $0.00 per day for days 21 to 90 |
| Urgent Care | Copayment for Urgent Care $40.00 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 $265.00 Air Ambulance: Copayment for Air Ambulance Services $265.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $265.00 Copayment for Medicare Covered Ambulance Services - Air $265.00 |
Health Care Services and Medical Supplies
HumanaChoice H5216-223 (PPO) 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 Copayment for Routine Care $20.00
Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 50% Coinsurance for Non-Medicare Covered Chiropractic Services 50% |
| 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 $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 Out-of-Network: Copayment for Medicare Covered Diabetic Supplies and Services $0.00 Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 18% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 25% |
| 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 $100.00 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 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $15.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $30.00 to $60.00 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% to 50% Coinsurance for Medicare Covered Lab Services 50% Copayment for Medicare Covered Diagnostic Radiological Services $500.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 40% to 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% to 50% Copayment for Medicare Covered Outpatient X-Ray Services $30.00 to $60.00 Coinsurance for Medicare Covered Outpatient X-Ray Services 50% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $250.00 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 Out-of-Network: $500.00 per day for days 1 to 20 $0.00 per day for days 21 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00 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 to $200.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% to 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% to 50% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| 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 $75.00 every three months 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 $75.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 Copayment for Routine Foot Care $0.00
Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $60.00 Coinsurance for Medicare Covered Podiatry Services 50% Copayment for Non-Medicare Covered Podiatry Services $60.00 Coinsurance for Non-Medicare Covered Podiatry Services 50% |
| 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 50 $0.00 per day for days 51 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 50% |
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 $30.00 Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $60.00 Coinsurance for Medicare Covered Comprehensive Dental 50% 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 $30.00 Copayment for Routine Eye Exams $0.00
Prior Authorization Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Prior Authorization Required for Eyewear Prior authorization required Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $60.00 Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0.00 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 $30.00 Copayment for Routine Hearing Exams $0.00
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $399.00 to $699.00
Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $60.00 Coinsurance for Medicare Covered Hearing Exams 50% 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 50% |
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