HumanaChoice Giveback H5216-445 (PPO)

Inpatient Hospital See details

Inpatient Hospital benefits are covered, including acute and psychiatric care. For acute care, you will pay a $370 copay for days 1-5, and no copay for days 6-90, while additional days (91-999) have no copay; non-Medicare-covered stays and upgrades are not covered. For psychiatric care, you will pay a $370 copay for days 1-5, and no copay for days 6-90; additional days and non-Medicare-covered stays are not covered.

Outpatient Services See details

Outpatient Services are covered, including all outpatient hospital services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a 20% coinsurance and a copay between $0 and $50, while Observation Services have a $370 copay. Ambulatory Surgical Center (ASC) Services have a minimum coinsurance of 20% and a maximum coinsurance of 20%, with no copay. Individual and Group Sessions for Outpatient Substance Abuse have a $20 copay, and Outpatient Blood Services have no copay.

Partial Hospitalization See details

Partial Hospitalization is covered with a $80 copay. Prior authorization is required.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered by the HumanaChoice Giveback H5216-445 (PPO) plan. Ground ambulance services have a copay of $315, and air ambulance services have a copay of $1250, with no coinsurance for either. Transportation services to any health-related location are not covered.

Emergency Services See details

Emergency Services, including Worldwide Emergency Services, has a $110 copay. Urgently Needed Services has a 20% coinsurance.

Primary Care See details

Primary Care Physician Services have a $20 copay, Chiropractic Services have a $15 copay, and Occupational Therapy Services have a 20% coinsurance. Physician Specialist Services have a $55 copay, and Mental Health Specialty Services have a $20 copay for individual and group sessions. Podiatry Services and Other Health Care Professional have a copay between $55 and $20. Psychiatric Services have a $20 copay for individual and group sessions, and Physical Therapy and Speech-Language Pathology Services have a 20% coinsurance. Additional Telehealth Benefits have a 20% coinsurance and a copay between $0 and $55, and Opioid Treatment Program Services have a $20 copay.

Preventive Services See details

The HumanaChoice Giveback H5216-445 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, and some services have a copay, including Medicare-covered Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay.

Hearing Services See details

Hearing Services include hearing exams with a $55 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription Hearing Aids are partially covered with a copay between $499 and $799. OTC Hearing Aids are not covered, and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.

Vision Services See details

Vision services include eye exams and eyewear benefits. Eye exams have a copay between $0 and $55, and routine eye exams have no copay. Eyewear has no copay, and the plan covers contact lenses and eyeglasses, but not eyeglass lenses, eyeglass frames, or upgrades.

Dental Services See details

Dental Services are covered, with a $1,000 maximum benefit per year for both in-network and out-of-network services. Medicare Dental Services have a $55 copay.

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 are covered with no copay, while 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, but prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the HumanaChoice Giveback H5216-445 (PPO) plan, but require prior authorization. The coinsurance is 20%.

Medical Equipment See details

Medical Equipment is covered, including Durable Medical Equipment (DME) with 12% coinsurance, Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered services, and Diabetic Equipment. Diabetic Supplies have no copay and 10-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have no copay.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services, including Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services, are covered under the HumanaChoice Giveback H5216-445 (PPO) plan. Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, and Lab Services also have a coinsurance of at most 20% with no copay. Outpatient X-Ray Services have a $20 copay, and a coinsurance of at most 20%. Therapeutic Radiological Services have a copay of at most $50, and a coinsurance of at most 20%.

Home Health Services See details

Home Health Services are covered by the HumanaChoice Giveback H5216-445 (PPO) plan 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 not covered by the HumanaChoice Giveback H5216-445 (PPO) plan. This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the HumanaChoice Giveback H5216-445 (PPO) 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 HumanaChoice Giveback H5216-445 (PPO) plan covers acupuncture with a $55 copay, and a meal benefit with no copay. However, 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.