HumanaChoice SNP-DE H5216-331 (PPO D-SNP)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0

Emergency Care:
Copayment for Emergency Care $0
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $0
Copayment for Medicare Covered Ambulance Services - Air $0

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0
Copayment for Medicare Covered Lab Services $0
Copayment for Medicare Covered Diagnostic Radiological Services $0
Copayment for Medicare Covered Therapeutic Radiological Services $0
Copayment for Medicare Covered Outpatient X-Ray Services $0
20% OP Diag Proc & Tests - OPH20% OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC20% OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

Out-of-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital per Stay $0

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Prior Authorization Required for Ambulatory Surgical Center Services

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $0
Copayment for Medicare Covered Group Sessions $0

In-Network:
$170 monthly allowance on a prepaid spending card. All plan members receive this amount to buy approved over the counter (OTC) health and wellness products at participating retailers or through the plan’s approved OTC mail order vendor. Plus, members may also use this money for eligible groceries, utilities, rent, and more if they have certain qualifying chronic condition(s) and meet other program criteria. Any unused amount rolls over each month and expires at the end of the plan year or upon disenrollment, whichever occurs first.

Out-of-Network:
95% coinsurance.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $0
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services

In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$0 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

In-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, scaling for moderate inflammation up to 1 per year.
$0 copayment for emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, scaling for moderate inflammation up to 1 per year.
$0 copayment for emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $0

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0