Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H5216-205-000 |
Plan Organization |
Humana |
Plan Type |
Local PPO |
Plan Name |
HumanaChoice SNP-DE H5216-205 (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 |
Plan Cost Sharing
Premium |
$0.00 |
Total Premium (Includes Part B) |
$135.50 |
Monthly Part C Premium |
$0.00 |
Monthly Part D Basic Premium |
$27.50 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$27.50 |
Monthly Part D Premium Full Assistance |
$0.00 |
Monthly Part D Premium 75% Assistance |
$6.90 |
Monthly Part D Premium 50% Assistance |
$13.70 |
Monthly Part D Premium 25% Assistance |
$20.60 |
Part D Drug Deductible |
$445.00 |
Annual Drug Deductible |
$445.00 |
Tiers Excluded From Deductible |
1 |
Part D Initial Coverage Limit |
$4130.00 |
Part D Catastrophic Coverage Threshold |
$6550.00 |
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 |
$0 copay |
Extractions |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Non-routine services |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Periodontics |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Restorative services |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
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 |
20% coinsurance |
Diagnostic tests and procedures |
- |
Out-of-Network |
Yes |
No |
$0 copay or 20% coinsurance |
Lab services |
- |
Out-of-Network |
Yes |
No |
$0 copay or 20% coinsurance |
Outpatient x-rays |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
Out-of-Network |
- |
- |
20% coinsurance per visit |
Specialist |
- |
Out-of-Network |
No |
No |
20% coinsurance per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$0 copay |
Urgent care |
- |
- |
- |
- |
$0 copay |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Routine foot care |
Yes |
Out-of-Network |
Yes |
No |
$0 copay |
Ground Ambulance
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
- |
- |
20% coinsurance |
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 |
$0 copay |
Hearing exam |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
$2,524 per stay |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$5,150 In and Out-of-network$3,450 In-network |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
Out-of-Network |
Yes |
- |
$0 copay or 20% 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 |
- |
$0 copay or 20% coinsurance |
Other Part B drugs |
- |
Out-of-Network |
Yes |
- |
$0 copay or 20% coinsurance |
Mental Health Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Inpatient hospital - psychiatric |
- |
Out-of-Network |
Yes |
No |
$2,339 per stay |
Outpatient group therapy visit |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Outpatient group therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Outpatient individual therapy visit |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Outpatient individual therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
20% 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 |
20% coinsurance per visit |
Preventive Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
No |
No |
$0 copay |
Preventive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Cleaning |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Dental x-ray(s) |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Fluoride treatment |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Oral exam |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Physical therapy and speech and language therapy visit |
- |
Out-of-Network |
Yes |
No |
20% coinsurance |
Skilled Nursing Facility
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
$20 per day for days 1 through 20$184 per day for days 21 through 100 |
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 |
|
- |
- |
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,
Burke 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,
Coffee County, Georgia,
Colquitt County, Georgia,
Columbia 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,
Lanier County, Georgia,
Laurens County, Georgia,
Lee County, Georgia,
Liberty County, Georgia,
Lincoln County, Georgia,
Long County, Georgia,
Lumpkin County, Georgia,
Macon County, Georgia,
Madison County, Georgia,
Marion County, Georgia,
Mcduffie 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,
Richmond 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,
Whitfield County, Georgia,
Wilcox County, Georgia,
Wilkes County, Georgia,
Wilkinson County, Georgia,
Worth 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.