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Humana Gold Plus H1036-153 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus H1036-153 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Gold Plus H1036-153 (HMO) in 2025, please refer to our full plan details page.
Humana Gold Plus H1036-153 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in OR. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Humana Gold Plus H1036-153 (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Humana Gold Plus H1036-153 (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Humana Gold Plus H1036-153 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $3.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $100.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Humana Gold Plus H1036-153 (HMO) plan has a $100 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you will pay a $12 copay for preferred generic drugs at a preferred pharmacy or through mail order, or a $20 copay at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs.
Additional Benefits
The Humana Gold Plus H1036-153 (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services may have copays depending on the service. Emergency and urgent care services have copays, and primary care visits are covered with no copay. Preventive, vision, and dental services have no copay, while hearing services have copays for hearing exams and hearing aids. The plan also covers ambulance services with copays, and offers additional services such as home health and skilled nursing facility stays with copays. There is 20% coinsurance for dialysis services, and durable medical equipment.
Inpatient Hospital See details
Inpatient hospital benefits are covered by Humana Gold Plus H1036-153 (HMO), with a copay of $395 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute has no copay for days 91-999. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for Humana Gold Plus H1036-153 (HMO) includes coverage for Outpatient Hospital Services with a copay between $0 and $395, Observation Services with a $395 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a copay between $40 and $50 for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Humana Gold Plus H1036-153 (HMO) plan, but requires prior authorization. The copay for this service is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Humana Gold Plus H1036-153 (HMO) plan, with no coinsurance for ambulance services. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a $1250 copay; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, have a copay of $125, and Urgently Needed Services have a copay of $55. There is no coinsurance for any of these services.
Primary Care See details
The Humana Gold Plus H1036-153 (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $45 copay, and physician specialist services with a $40 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have varying copays depending on the specific service, and physical therapy and speech-language pathology services have a $45 copay. Additional telehealth benefits have a copay between $0 and $55, and routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include an annual physical exam with no copay. Additional preventive services are covered, and other services such as health education, in-home safety assessments, and more are not covered. Other services like glaucoma screenings, diabetes self-management training, and more have no copay.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $40 copay, routine hearing exams have no copay, and fitting/evaluation for hearing aids has no copay. Prescription hearing aids (all types) have a copay between $599 and $899, while prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams and eyewear. Eye exams have a copay of $0-$40, and routine eye exams have no copay, while eyewear has a combined maximum benefit of $100 per year, and contact lenses and eyeglasses have no copay.
Dental Services See details
The Humana Gold Plus H1036-153 (HMO) plan covers Medicare Dental Services with a $40 copay, and other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay, but with some limitations on the number of visits allowed. This plan does not cover fluoride treatment, maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Humana Gold Plus H1036-153 (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 10% to 20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay between $0 and $55 for diagnostic procedures, and no copay for lab services. Radiological Services include coverage for diagnostic services with a copay up to $395, therapeutic services with 20% coinsurance, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the Humana Gold Plus H1036-153 (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Humana Gold Plus H1036-153 (HMO) plan. Specifically, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Gold Plus H1036-153 (HMO) plan, but require prior authorization. You will pay a $10 copay for days 1-20, a $214 copay for days 21-55, and no copay for days 56-100.
Other Services See details
The Humana Gold Plus H1036-153 (HMO) plan covers acupuncture with a $40 copay, and it covers a meal benefit with no copay. Other services such as over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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