Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-206-000
Plan Organization Humana
Plan Type Local PPO
Plan Name HumanaChoice SNP-DE H5216-206 (PPO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 4 Stars
Plan Cost Sharing
Premium $23.60
Total Premium (Includes Part B) $159.10
Monthly Part D Basic Premium $23.60
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $23.60
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $5.90
Monthly Part D Premium 50% Assistance $11.80
Monthly Part D Premium 25% Assistance $17.70
Part D Drug Deductible $435.00
Annual Drug Deductible $435.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Endodontics Yes In-Network Yes No $0 copay
Diagnostic services No - - - Not covered
Restorative services Yes In-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No 50%
Non-routine services Yes In-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 50%
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - In-Network Yes No $0 or $15 or 20%
Diagnostic tests and procedures - In-Network Yes No $0 or $0-15 or 20%
Lab services - In-Network Yes No $0 or $0-15 or 20%
Outpatient x-rays - Out-of-Network Yes No $0-120 or 20%
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No $15
Routine foot care Yes Out-of-Network Yes No $15
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $235
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network Yes No $0 copay
Hearing aids Yes In-Network No No $99-399
Hearing exam - Out-of-Network Yes No $15
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $325 per day for days 1 through 6 $0 per day for days 7 through 90
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% per item
Diabetes supplies - Out-of-Network Yes - $0-15 or 20% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - Out-of-Network Yes No $40-120
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No $0 or $40
Inpatient hospital - psychiatric - Out-of-Network Yes No $587 per day for days 1 through 3 $0 per day for days 4 through 90
Outpatient group therapy visit with a psychiatrist - In-Network Yes No $0 or $40
Outpatient individual therapy visit - Out-of-Network Yes No $40-120
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0 or $120 or 20% per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes Out-of-Network No No 50%
Fluoride treatment Yes Out-of-Network No No 50%
Oral exam Yes Out-of-Network No No 50%
Cleaning Yes Out-of-Network No No 50%
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $15
Occupational therapy visit - In-Network Yes No $0 or $15
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0 per day for days 1 through 20 $178 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network Yes No 50%
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass frames No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network Yes No $0 copay
Other No - - - Not covered
Contact lenses Yes In-Network Yes No $0 copay
Eyeglass lenses No - - - Not covered
Routine eye exam Yes Out-of-Network Yes No $0 copay
Upgrades - - - - Not covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network No No $15 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 or $90 per visit (always covered)
Urgent care - - - - $0 or $0-15 or 20% per visit (always covered)
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In and Out-of-network $6,700 In-network
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - $0-15 or 20%
Other Part B drugs - Out-of-Network Yes - $0-15 or 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Covered
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Ben Hill County, Georgia, Berrien County, Georgia, Bibb County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Brooks County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Butts County, Georgia, Calhoun County, Georgia, Camden County, Georgia, Candler County, Georgia, Carroll County, Georgia, Catoosa County, Georgia, Charlton County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Clinch County, Georgia, Cobb County, Georgia, Colquitt County, Georgia, Cook County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dade County, Georgia, Dawson County, Georgia, Decatur County, Georgia, Dekalb County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Early County, Georgia, Echols County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Gilmer County, Georgia, Glascock County, Georgia, Glynn County, Georgia, Gordon County, Georgia, Grady County, Georgia, Greene County, Georgia, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jeff Davis County, Georgia, Jefferson County, Georgia, Jenkins County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Laurens County, Georgia, Lee County, Georgia, Liberty County, Georgia, Long County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Miller County, Georgia, Mitchell County, Georgia, Monroe County, Georgia, Montgomery County, Georgia, Morgan County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Rockdale County, Georgia, Schley County, Georgia, Screven County, Georgia, Seminole County, Georgia, Spalding County, Georgia, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Terrell County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Upson County, Georgia, Walton County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Webster County, Georgia, Wheeler County, Georgia, White County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia, Worth County, Georgia

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