HumanaChoice H5216-425 (PPO)

Inpatient Hospital See details

Inpatient Hospital services include coverage for Inpatient Hospital-Acute with a $325 copay for days 1-7, and no copay for days 8-90, as well as Inpatient Hospital Psychiatric with a $325 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 stays and upgrades for Inpatient Hospital-Acute and Additional days for Inpatient Hospital Psychiatric and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.

Outpatient Services See details

Outpatient Services includes coverage for all outpatient hospital services, with a copay between $0 and $325, and observation services with a $325 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services have no copay. Outpatient Substance Abuse Services are covered with a copay between $40 and $90 for individual and group sessions.

Partial Hospitalization See details

Partial Hospitalization is covered by the HumanaChoice H5216-425 (PPO) plan, with a $60 copay. Prior authorization is required.

Ambulance and Transportation Services See details

Ambulance and Transportation Services, including ground and air ambulance services, are covered by the HumanaChoice H5216-425 (PPO) plan. Ground and air ambulance services have a copay of $315.00, while transportation services to a plan-approved health-related location have no copay for 24 one-way trips per year. 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. Emergency Services and Worldwide Emergency Coverage have a $100 copay, Urgently Needed Services has a $45 copay, and there is no coinsurance for these services. Worldwide Urgent Coverage and Worldwide Emergency Transportation each have a $100 copay.

Primary Care See details

HumanaChoice H5216-425 (PPO) covers primary care physician services with no copay. Chiropractic services have a $15 copay, and occupational therapy services have a copay between $20 and $35. Physician specialist services have a $40 copay, and mental health specialty services, including individual and group sessions, have a $40 copay.

Podiatry services have a $40 copay, other healthcare professionals have a copay between $0 and $40, and psychiatric services, including individual and group sessions, have a $40 copay. Physical therapy and speech-language pathology services have a copay between $20 and $35, and additional telehealth benefits have a copay between $0 and $45. Opioid treatment program services have a copay between $40 and $90.

Preventive Services See details

The HumanaChoice H5216-425 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, and other services such as health education, and several others are not covered.

Hearing Services See details

Hearing exams are covered with a $40 copay. Routine hearing exams are covered with no copay for one visit every year, and fitting/evaluation for hearing aids has no copay. Prescription hearing aids are partially covered; Prescription Hearing Aids (all types) have a copay between $399 and $699 for two visits every year, but Inner Ear, Outer Ear, and Over the Ear hearing aids are not covered. OTC hearing aids are covered, with a maximum benefit of $50 every three months.

Vision Services See details

Vision services include eye exams and eyewear. Eye exams have a copay of $0-$40, and eyewear has no copay.

Dental Services See details

Dental Services are covered, with a $1,500 annual maximum benefit. Medicare Dental Services have a $40 copay, while Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics fixed, and Oral and Maxillofacial Surgery have no copay. Fluoride Treatment, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. You may have a $35 copay for Medicare Part B Insulin Drugs, and the coinsurance for the listed drugs is between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the HumanaChoice H5216-425 (PPO) plan. The coinsurance for dialysis services is 20%.

Medical Equipment See details

Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance and requires authorization, while Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies have a 10-20% coinsurance with no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services are covered under the HumanaChoice H5216-425 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $325, while Therapeutic Radiological Services have a copay of at most $40 and a 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 H5216-425 (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 specific services including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required, and there is a copay for some services, but the specific copay information is not provided.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered under the HumanaChoice H5216-425 (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100.

Other Services See details

The HumanaChoice H5216-425 (PPO) plan covers acupuncture with a $40 copay, and covers over-the-counter items, and a meal benefit with no copay. The plan does not cover 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.