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HumanaChoice H5216-196 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-196 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-196 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-196 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in New Mexico. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-196 (PPO) 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 HumanaChoice H5216-196 (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 H5216-196 (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 $5.00. 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 $200.00 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 combined Maximum Out-Of-Pocket cost of $8950.00 (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 $8950.00 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
The HumanaChoice H5216-196 (PPO) plan has a $200 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you'll pay $12 for preferred generic drugs at a standard pharmacy and 38% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-196 (PPO) plan offers a range of benefits, including coverage for inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with a $125 copay. This plan also covers primary care, preventive, hearing, vision, and dental services, with some services having no copay and others with copays ranging from $20 to $45. Additionally, this plan provides coverage for home infusion, dialysis, medical equipment, diagnostic and radiological services, home health, and skilled nursing facility services, with varying cost-sharing structures.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with a copay of $295 for days 1-6 and no copay for days 7-90. Additional days for inpatient hospital-acute have no copay, while non-Medicare-covered stays and upgrades for inpatient hospital-acute and psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $350, and observation services with a copay of $295. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $20 copay for both individual and group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will have a $100 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services. Ground ambulance services have a $315 copay, while air ambulance services have a $630 copay; there is no coinsurance for either service. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-196 (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay, while all Worldwide Emergency Services have a $125 copay.
Primary Care See details
The HumanaChoice H5216-196 (PPO) plan offers primary care services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $45 copay, and mental health specialty services with a $20 copay for individual and group sessions. Additionally, podiatry services have a $45 copay, other health care professional services have copays ranging from $0 to $45, psychiatric services individual and group sessions have a $20 copay, physical therapy and speech-language pathology services have a $45 copay, additional telehealth benefits have copays from $0 to $55, and opioid treatment program services have a $20 copay.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, and additional preventive services, including fitness benefits, with no copay. Other preventive services, like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, are covered with no copay. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
Hearing exams are covered with a $45 copay, and routine hearing exams are covered with no copay, once per year. Fitting/Evaluation for Hearing Aids are covered with no copay. Prescription hearing aids (all types) are covered with a copay between $499 and $799, twice per year, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The HumanaChoice H5216-196 (PPO) plan covers eye exams with a copay of $0-$45, and also covers eyewear. Eyewear includes contact lenses and eyeglasses (lenses and frames) with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-196 (PPO) plan covers Medicare Dental Services with a $45 copay, and covers Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. Adjunctive General Services are covered with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the HumanaChoice H5216-196 (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0-20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-196 (PPO) plan, but require prior authorization. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 15% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies also have a 20% coinsurance. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice H5216-196 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $55, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a copay up to $40 and coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-196 (PPO) plan with no copay and no coinsurance, though 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 Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required, and copay information is available in the plan details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-196 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare coverage, and non-Medicare covered stays, are not covered.
Other Services See details
Other Services includes acupuncture with a $45 copay, and a meal benefit with no copay. 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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