HumanaChoice H5216-203 (PPO) | 2021 Medicare Advantage Plan

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

Plan Drug Info

Formulary Link

Drug Formulary Directory

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

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.