HumanaChoice H5216-358 (PPO) H5216-358-000 2024 Plan Details and Costs (2024)

HumanaChoice H5216-358 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-358-000

Texas Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Texas Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$395.00
Out-of-pocket maximum$7,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $65.00

Inpatient hospital careIn-Network:

Acute Hospital Services:
$320.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services

Urgent care
Urgent Care:
Copayment for Urgent Care $55.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00

Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $100.00

Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

HumanaChoice H5216-358 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-358 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services

Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $175.00
Copayment for Medicare-covered Lab Services $0.00 to $55.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $325.00
Copayment for Medicare-covered Therapeutic Radiological Services $40.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $125.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services

Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $295.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $320.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $250.00
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30.00 to $100.00
Copayment for Medicare-covered Group Sessions $30.00 to $100.00
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $40.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45.00
Prior Authorization Required for Podiatry Services

Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 60
$203.00 per day for days 61 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn Network:
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.$0 copayment for bridge recementation, bridges-pontic, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.$0 copayment for bridges-crown up to 2 every 5 years.$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.$0 copayment for emergency diagnostic exam up to 1 per year.$0 copayment for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.$0 copayment for periodontal maintenance up to 4 per year.$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.$1,500 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits.

Out of Network:
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.$0 copayment for bridge recementation, bridges-pontic, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.$0 copayment for bridges-crown up to 2 every 5 years.$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.$0 copayment for emergency diagnostic exam up to 1 per year.$0 copayment for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.$0 copayment for periodontal maintenance up to 4 per year.$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.$1,500 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits.Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $45.00
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75.00 every year for in and out of network services combined
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00

  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00

  • Maximum 2 Hearing Aids every year
$699 copayment per ear per year for advanced level hearing aid purchase or $999 copayment per ear per year for premium level hearing aid purchase.

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The HumanaChoice H5216-358 (PPO) offers prescription drug coverage, with an annual drug deductible of $395.00 (excludes Tiers 1 and 2)

    Coverage

    Cost

    Coverage & Cost

    Annual drug deductible$395.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
  • Tier 2
  • Standard retail $5.00
  • Preferred mail order $5.00
  • Standard mail order $20.00
  • Annual drug deductible$395.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Tier 2
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$395.00 (excludes Tiers 1 and 2)
    Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
  • Tier 2
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $60.00
  • When reviewing Texas Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Texas that offer similar benefits at similar or lower prices than the plan above. Call 1-855-298-6309 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents
    • Summary of benefits
    • Evidence of coverage
    • Star ratings

    Texas Counties Served

    Angelina Aransas Bastrop Bee Bell Bowie Brazos Caldwell Cass Chambers Cherokee Colorado Cooke Coryell Delta Denton Ector Ellis Fannin Fayette Grayson Gregg Hale Hardin Harris Harrison Hays Henderson Hill Hood Hopkins Houston Howard Jasper Jefferson Jim Wells Johnson Kaufman Kleberg Lamar Lampasas Liberty Llano Lubbock Matagorda Maverick Mclennan Midland Milam Montague Nacogdoches Navarro Nueces Orange Potter Randall Red River Rockwall Rusk San Jacinto San Patricio Smith Tarrant Taylor Titus Tom Green Travis Tyler Van Zandt Victoria Walker Waller Washington Wharton Wichita Williamson Wise Wood

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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    HumanaChoice H5216-358 (PPO) H5216-358-000 2024 Plan Details and Costs (2024)
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