Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H5216-203-001 |
Plan Organization |
Humana |
Plan Type |
Local PPO |
Plan Name |
HumanaChoice H5216-203 (PPO) |
Plan Organization Type |
Local CCP |
Drugs Covered |
Yes |
Doctors Choice |
Any Doctor |
Benefit Type |
Enhanced Alternative |
Special Needs Plan |
No |
Overall Star Rating |
4 |
Plan Cost Sharing
Premium |
$0.00 |
Total Premium (Includes Part B) |
$135.50 |
Monthly Part C Premium |
$0.00 |
Monthly Part D Basic Premium |
$0.00 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$0.00 |
Monthly Part D Premium Full Assistance |
$0.00 |
Monthly Part D Premium 75% Assistance |
$0.00 |
Monthly Part D Premium 50% Assistance |
$0.00 |
Monthly Part D Premium 25% Assistance |
$0.00 |
Part D Drug Deductible |
$0.00 |
Part D Initial Coverage Limit |
$4130.00 |
Part D Catastrophic Coverage Threshold |
$6550.00 |
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) |
$7550.00 |
Gap Coverage |
No |
Medicare Advantage Plan Health Benefits
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 |
Comprehensive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic services |
No |
- |
- |
- |
Not covered |
Endodontics |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Extractions |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Non-routine services |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Periodontics |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Restorative services |
Yes |
Out-of-Network |
Yes |
No |
55-75% coinsurance |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Diagnostic tests and procedures |
- |
Out-of-Network |
Yes |
No |
$0 copay or 40% coinsurance |
Lab services |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Outpatient x-rays |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
Out-of-Network |
- |
- |
40% coinsurance per visit |
Specialist |
- |
Out-of-Network |
No |
No |
40% coinsurance per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$90 copay per visit (always covered) |
Urgent care |
- |
- |
- |
- |
$5-35 copay or 40% coinsurance per visit (always covered) |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Routine foot care |
- |
- |
- |
- |
Not covered |
Ground Ambulance
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
- |
- |
$290 copay |
Health Plan Deductible
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$0 |
Hearing
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Fitting/evaluation |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Hearing aids |
Yes |
Out-of-Network |
No |
No |
$699-999 copay |
Hearing exam |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
40% per stay |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$11,300 In and Out-of-network$7,550 In-network |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
Out-of-Network |
Yes |
- |
40% coinsurance per item |
Durable medical equipment (e.g., wheelchairs, oxygen) |
- |
Out-of-Network |
Yes |
- |
20% coinsurance per item |
Prosthetics (e.g., braces, artificial limbs) |
- |
Out-of-Network |
Yes |
- |
20% coinsurance per item |
Medicare Part B Drugs
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Chemotherapy |
- |
Out-of-Network |
Yes |
- |
40% coinsurance |
Other Part B drugs |
- |
Out-of-Network |
Yes |
- |
40% coinsurance |
Mental Health Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Inpatient hospital - psychiatric |
- |
Out-of-Network |
Yes |
No |
50% per stay |
Outpatient group therapy visit |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Outpatient group therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Outpatient individual therapy visit |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Outpatient individual therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Optional Supplemental Benefits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
No |
Other Health Plan Deductibles?
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
In-Network |
- |
- |
No |
Outpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
40% coinsurance per visit |
Preventive Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
No |
No |
$0 copay or 40% coinsurance |
Preventive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Cleaning |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Dental x-ray(s) |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Fluoride treatment |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Oral exam |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Physical therapy and speech and language therapy visit |
- |
Out-of-Network |
Yes |
No |
40% coinsurance |
Skilled Nursing Facility
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
40% per stay |
Transportation
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Vision
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Contact lenses |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Eyeglass frames |
No |
- |
- |
- |
Not covered |
Eyeglass lenses |
No |
- |
- |
- |
Not covered |
Eyeglasses (frames and lenses) |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Other |
No |
- |
- |
- |
Not covered |
Routine eye exam |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Upgrades |
- |
- |
- |
- |
Not covered |
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
No |
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
Barrow County, Georgia,
Bartow County, Georgia,
Butts County, Georgia,
Carroll County, Georgia,
Catoosa County, Georgia,
Chattahoochee County, Georgia,
Chattooga County, Georgia,
Cherokee County, Georgia,
Clarke County, Georgia,
Clayton County, Georgia,
Cobb County, Georgia,
Coweta County, Georgia,
Dade County, Georgia,
Dawson County, Georgia,
Dekalb County, Georgia,
Douglas County, Georgia,
Fayette County, Georgia,
Floyd County, Georgia,
Forsyth County, Georgia,
Fulton County, Georgia,
Gordon County, Georgia,
Gwinnett County, Georgia,
Hall County, Georgia,
Haralson County, Georgia,
Harris County, Georgia,
Heard County, Georgia,
Henry County, Georgia,
Jackson County, Georgia,
Jasper County, Georgia,
Lamar County, Georgia,
Madison County, Georgia,
Marion County, Georgia,
Meriwether County, Georgia,
Murray County, Georgia,
Muscogee County, Georgia,
Newton County, Georgia,
Oconee County, Georgia,
Oglethorpe County, Georgia,
Paulding County, Georgia,
Pickens County, Georgia,
Pike County, Georgia,
Polk County, Georgia,
Rockdale County, Georgia,
Spalding County, Georgia,
Stewart County, Georgia,
Talbot County, Georgia,
Troup County, Georgia,
Upson County, Georgia,
Walton County, Georgia,
Webster County, Georgia,
Whitfield County, Georgia
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