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Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) in 2025, please refer to our full plan details page.
Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) is a HMO D-SNP plan offered by Humana Inc. available for enrollment in 2025 to people living in Southwest Virginia. The overall rating for this plan is not yet available for 2025.
It's important to know that Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP).
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 SNP-DE H2875-004 (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $30.70. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 $590.00 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 $9350.00 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 SNP-DE H2875-004 (HMO D-SNP) plan has a $590.00 deductible for prescription drugs. After the deductible is met, you will pay the costs for your drugs in each tier. This plan's premium may be reduced if you qualify for the low-income subsidy, and the monthly Part D premium is $30.70 with this subsidy.
Additional Benefits
The Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan offers a range of benefits with varying costs. You'll pay a $2,185 copay for inpatient acute hospital care, and a $2,036 copay for inpatient psychiatric care. The plan has a $45 copay for specialist visits, and covers dental services with no copay for many services, as well as an annual maximum benefit of $3,000. This plan includes a $110 copay for emergency services, and covers outpatient services with 20% coinsurance, and outpatient substance abuse services with a 20% coinsurance. Preventive services are covered with no copay, and hearing and vision services are covered, with no copay for routine eye exams. The plan also offers transportation services, a meal benefit, and coverage for over-the-counter items, as well as coverage for many other services with varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered by the Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan. For acute care, there is a copay of $2,185 per admission or stay, and for psychiatric care, there is a copay of $2,036 per admission or stay. Additional days for inpatient acute hospital care are covered with no copay, while non-Medicare-covered stays and upgrades are not covered. Additional days and non-Medicare-covered stays for psychiatric care are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, and ambulatory surgical center (ASC) services, are covered with a 20% coinsurance. Outpatient substance abuse services, including individual and group sessions, are covered with a coinsurance between 20% and 20%. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services, with a $315 copay for each service. Transportation Services to plan-approved health-related locations are covered with no copay, up to 60 one-way trips per year via taxi, bus/subway, or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $45 copay, and there is no coinsurance for any of these services.
Primary Care See details
The Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan covers Primary Care services, including Primary Care Physician Services with 20% coinsurance, Chiropractic Services with 20% coinsurance and no copay for routine care, Occupational Therapy Services with 20% coinsurance, Physician Specialist Services with a $45 copay, Mental Health Specialty Services with 20% coinsurance, Podiatry Services with a $45 copay for Medicare-covered services and routine foot care, Other Health Care Professional services with 20% coinsurance and a $45 copay, Psychiatric Services with 20% coinsurance, Physical Therapy and Speech-Language Pathology Services with 20% coinsurance, Additional Telehealth Benefits with 20% coinsurance and a copay between $0 and $45, and Opioid Treatment Program Services with 20% coinsurance.
Preventive Services See details
Preventive services include an annual physical exam with no copay, and other services that may have a copay. Other covered services include kidney disease education and several other preventive services, all with no copay.
Hearing Services See details
Hearing exams are covered with a $45 copay, and routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan covers vision services including eye exams and eyewear, with no copay for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay, and other dental services with a $3,000 annual maximum benefit. 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 are covered with no copay, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0-20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan, but prior authorization is required. You will be responsible for 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetics/Medical Supplies, including Medicare-covered Prosthetic Devices and Medical Supplies, with a 20% coinsurance and no copay. Diabetic Supplies and Therapeutic Shoes/Inserts are covered with a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a coinsurance of at most 20% and a copay of at most $45.00, and lab services with a coinsurance of at most 20% and no copay. Therapeutic Radiological Services have a coinsurance of at most 20% and a copay of at most $45.00, while Outpatient X-Ray Services have a coinsurance of at most 20% and a copay of $45.00.
Home Health Services See details
Home Health Services are covered 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 covered, but the plan does not cover the specific sub-services of 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. Prior authorization is required, and there is coinsurance for some services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP) plan covers acupuncture with a $45 copay, up to 20 treatments per year, and also covers over-the-counter items with a maximum benefit of $1440 per year. The plan also covers a meal benefit with no copay. However, several other "Other Services" are not covered.
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