HumanaChoice H5216-152 (PPO)
HumanaChoice H5216-152 (PPO) H5216-152 Plan Details
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
HumanaChoice H5216-152 (PPO) H5216-152 Plan Details
HumanaChoice H5216-152 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-152
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Virginia Counties Served
Roanoke
Virginia Beach City
Spotsylvania
Portsmouth City
Chesapeake City
Fauquier
Botetourt
Hampton City
Manassas City
Fredericksburg City
Petersburg City
Salem
Loudoun
Hanover
Alexandria City
Norfolk City
Williamsburg City
Montgomery
Frederick
Floyd
Suffolk City
Louisa
Stafford
Rappahannock
Franklin City
King and Queen
Amherst
Manassas Park City
Radford
Sussex
Prince George
Shenandoah
King George
Southampton
Essex
Richmond City
Poquoson City
Surry
Appomattox
Amelia
Pittsylvania
Colonial Heights City
Campbell
Bland
Chesterfield
Winchester City
Craig
Bedford
Roanoke City
Northampton
Isle of Wight
Henrico
Danville City
Hopewell City
Warren
Richmond
Falls Church City
Page
New Kent
Caroline
Arlington
Prince William
Lynchburg City
James City
Martinsville City
Dinwiddie
Franklin
Newport News City
Accomack
Powhatan
Henry
York
Westmoreland
Northumberland
Pulaski
Gloucester
Cumberland
Goochland
Clarke
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $3400 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| 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 $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $35.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $460.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Copayment for Acute Hospital Services per Stay $460.00 |
| Urgent Care | Copayment for Urgent Care $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $135.00 |
| Emergency Room Visit | Copayment for Emergency Care $135.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $135.00 Copayment for Worldwide Emergency Transportation $135.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300.00 Air Ambulance: Copayment for Air Ambulance Services $300.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300.00 Copayment for Medicare Covered Ambulance Services - Air $300.00 |
Health Care Services and Medical Supplies
HumanaChoice H5216-152 (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 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $20.00 |
| 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 Out-of-Network: Copayment for Medicare Covered Diabetic Supplies and Services $10.00 Coinsurance for Medicare Covered Diabetic Supplies and Services 10% to 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| 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 $85.00 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 $35.00 to $295.00 Copayment for Medicare-covered Therapeutic Radiological Services $35.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $95.00 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 $0.00 to $85.00 Copayment for Medicare Covered Lab Services $0.00 to $50.00 Copayment for Medicare Covered Diagnostic Radiological Services $35.00 to $295.00 Copayment for Medicare Covered Therapeutic Radiological Services $35.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $95.00 |
| 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: Copayment for Medicare Covered Home Health $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $460.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Copayment for Psychiatric Hospital Services per Stay $460.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $35.00 Copayment for Medicare Covered Group Sessions $35.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $350.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $250.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $300.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $250.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 to $85.00 Copayment for Medicare-covered Group Sessions $40.00 to $85.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $40.00 to $85.00 |
| 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 $35.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $35.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $196.00 per day for days 21 to 38 $0.00 per day for days 39 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: $0.00 per day for days 1 to 20 $196.00 per day for days 21 to 38 $0.00 per day for days 39 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In Network: $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Out of Network: $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
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 $35.00 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 $0.00 to $35.00 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 $35.00 Copayment for Routine Hearing Exams $0.00
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $35.00 Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 50% Coinsurance for Non-Medicare Covered Hearing Aids 50% |
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 |
