HumanaChoice H5216-300 (PPO)

Inpatient Hospital See details

Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $280 for days 1-9, and no copay for days 10-90 for Inpatient Hospital-Acute, and a copay of $262 for days 1-9, and no copay for days 10-90 for Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute has no copay for days 91-999. 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 are covered by the HumanaChoice H5216-300 (PPO) plan, including outpatient hospital services with a copay between $0 and $350, observation services with a $280 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have copays between $30 and $75 for individual and group sessions, and outpatient blood services are covered with no copay.

Partial Hospitalization See details

Partial Hospitalization is covered by the HumanaChoice H5216-300 (PPO) plan with a $40 copay. Prior authorization is required for this benefit.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a $315 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.

Emergency Services See details

Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered by the HumanaChoice H5216-300 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay. There is no coinsurance for any of these services.

Primary Care See details

The HumanaChoice H5216-300 (PPO) plan covers Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $30 copay, Physician Specialist Services with a $45 copay, Mental Health Specialty Services with a $30 copay, Other Health Care Professional services with a copay between $0 and $45, Psychiatric Services with a $30 copay, Physical Therapy and Speech-Language Pathology Services with a $30 copay, Additional Telehealth Benefits with a copay between $0 and $55, and Opioid Treatment Program Services with a copay between $30 and $75. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.

Preventive Services See details

The HumanaChoice H5216-300 (PPO) plan covers preventive services, including an annual physical exam with no copay. This plan also covers additional preventive services, and kidney disease education services, with no copay for Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.

Hearing Services See details

Hearing Services include hearing exams with a $45 copay, routine hearing exams with no copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a copay between $599 and $899. 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

Vision Services include eye exams and eyewear. Eye exams have a copay between $0 and $45, and eyewear has no copay; both benefits require prior authorization.

Contact lenses and eyeglasses (lenses and frames) are covered with no copay, and the plan covers a combined maximum of $150 for eyewear.

Eyeglass lenses, eyeglass frames, and upgrades are not covered.

Dental Services See details

The HumanaChoice H5216-300 (PPO) plan covers Medicare Dental Services with a $45 copay, and other dental services with a maximum benefit of $1750 per year. 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. However, fluoride treatment, maxillofacial prosthetics, implants services, and orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered by the HumanaChoice H5216-300 (PPO) plan and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the HumanaChoice H5216-300 (PPO) plan. This plan requires prior authorization, and has a coinsurance of 20% for dialysis services.

Medical Equipment See details

Medical Equipment is covered by HumanaChoice H5216-300 (PPO). Durable Medical Equipment (DME), Prosthetic Devices, and Medical Supplies have no copay and no coinsurance. For Diabetic Supplies, there is no copay and 10% coinsurance, and for Diabetic Therapeutic Shoes/Inserts there is a $10 copay.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services include coverage for all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $75, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have a copay between $30 and $50, and Outpatient X-Ray Services have no copay.

Home Health Services See details

HumanaChoice H5216-300 (PPO) covers Home Health Services with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are covered by the HumanaChoice H5216-300 (PPO) plan, but specific services like Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for some services, but the details are not provided.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-300 (PPO) plan. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.

Other Services See details

Other Services include acupuncture and meal benefits. Acupuncture has a $45 copay, and is limited to 20 treatments per year. Meal benefits have 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.