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HumanaChoice Giveback H5216-116 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice Giveback H5216-116 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice Giveback H5216-116 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice Giveback H5216-116 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Pennsylvania and New Jersey. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice Giveback H5216-116 (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HumanaChoice Giveback H5216-116 (PPO).
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 HumanaChoice Giveback H5216-116 (PPO), 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 $50.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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
Prescription drugs are not covered by HumanaChoice Giveback H5216-116 (PPO).
Additional Benefits
The HumanaChoice Giveback H5216-116 (PPO) plan offers a range of benefits, including inpatient hospital stays with copays, outpatient services with varying copays, and coverage for ambulance and transportation services. You'll also find coverage for primary care, preventive, hearing, vision, and dental services, with services like home health and home infusion having specific cost-sharing arrangements. This plan provides coverage for emergency services, along with specialized services like dialysis, medical equipment, and diagnostic and radiological services. The plan also offers additional benefits like acupuncture, over-the-counter items, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $495 copay for days 1-6, and no copay for days 7-90, while for Inpatient Hospital Psychiatric, you will pay a $450 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stay and Upgrades for Inpatient Hospital-Acute, and Additional days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $800, observation services with a $495 copay, ambulatory surgical center (ASC) services with no copay, outpatient substance abuse services with a copay between $25 and $75 for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice Giveback H5216-116 (PPO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services with a $315 copay. Transportation Services to a plan-approved health-related location are covered with no copay, up to 24 one-way trips per year using a taxi, bus/subway, or medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $140 copay, and Urgently Needed Services have a $60 copay, with no coinsurance for either. Worldwide Emergency Services has a $140 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, with no coinsurance.
Primary Care See details
The HumanaChoice Giveback H5216-116 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $10-$25 copay, physician specialist services with a $25 copay, mental health specialty services with a $25 copay, and physical therapy and speech-language pathology services with a $10-$25 copay. The plan also covers additional telehealth benefits with a $0-$60 copay and opioid treatment program services with a $25-$75 copay.
Preventive Services See details
Preventive Services, including Medicare-covered services, are covered, with no copay for annual physical exams and no copay for several other preventive services, including glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. Additional preventive services require prior authorization and have a copay.
Hearing Services See details
Hearing exams are covered with a $25 copay, routine hearing exams are covered with no copay, and fitting/evaluation for hearing aids has no copay. Prescription hearing aids are covered with a copay between $499 and $799, while OTC hearing aids are covered with a maximum benefit of $25.
Vision Services See details
The HumanaChoice Giveback H5216-116 (PPO) plan covers vision services, including eye exams with a copay between $0 and $25 and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice Giveback H5216-116 (PPO) plan covers Medicare Dental Services with a $25 copay, and other dental services with a maximum plan benefit of $1000 per year. The plan also covers oral exams and dental x-rays with no copay, and other preventive dental services with no copay. Fluoride treatment, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the HumanaChoice Giveback H5216-116 (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice Giveback H5216-116 (PPO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment includes Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, with varying cost-sharing. DME has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a 10% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $325, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice Giveback H5216-116 (PPO) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice Giveback H5216-116 (PPO) covers Cardiac Rehabilitation Services, but the specific services including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice Giveback H5216-116 (PPO) plan, but require prior authorization. The plan has a copay of $20 for days 1-20, and a copay of $214 for days 21-100, with no coinsurance.
Other Services See details
The HumanaChoice Giveback H5216-116 (PPO) plan covers acupuncture with a $25 copay, but only up to 20 treatments per year, and it also covers over-the-counter items with a $25 monthly maximum. The plan also covers a meal benefit with no copay. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more are not covered.
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