2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Humana Gold Choice H2944-163 (PFFS) | ||||
Location: | Coos, New Hampshire Click to see other locations | ||||
Plan ID: | H2944 - 163 - 0 Click to see other plans | ||||
Member Services: | 1-800-457-4708 TTY users 711 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Humana Gold Choice H2944-163 (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $64.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | PFFS * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in (H2944 - 163): | 13 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$64.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
This plan does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$155 yearly deductible. Contact the plan for services that apply. | |||||
$6 700 out-of-pocket limit. | |||||
In-Network: This limit includes only Medicare-covered services. | |||||
Out-Of-Network: This limit includes only Medicare-covered services. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs). | |||||
20% of the cost for Part B-covered chemotherapy drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$64.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
This plan does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$155 yearly deductible. Contact the plan for services that apply. | |||||
$6 700 out-of-pocket limit. | |||||
In-Network: This limit includes only Medicare-covered services. | |||||
Out-Of-Network: This limit includes only Medicare-covered services. | |||||
Doctor and Hospital Choice | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
You will not be charged additional cost sharing for professional services. | |||||
For additional hospital days: | |||||
Days 91 - 150: $550 copay per day | |||||
Days 151 and beyond: $0 copay per day | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care') | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $137.50 copay per day | |||||
Home Health Care | |||||
$0 copay for each Medicare-covered home health visit. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
20% of the cost for each primary care doctor visit for Medicare-covered benefits. | |||||
20% of the cost for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
20% of the cost for each Medicare-covered individual or group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
20% of the cost for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit. | |||||
20% of the cost for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
$25 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
Outpatient Rehabilitation Services | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. | |||||
20% of the cost for Medicare-covered Occupational Therapy visits. | |||||
20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
20% of the cost for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered items. | |||||
20% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
20% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
$0 to $10 copay [or 20% of the cost] for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for Medicare-covered prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
20% of the cost for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease. | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs). | |||||
20% of the cost for Part B-covered chemotherapy drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
Hearing Services | |||||
In general routine hearing exams and hearing aids not covered. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Health/Wellness Education | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$25.40 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
** Extra Benefits ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$1 500 plan coverage limit for comprehensive dental benefits every year. | |||||
30% of the cost for preventive dental services. | |||||
55% to 75% of the cost for comprehensive dental services. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$25.40 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
** Additional Benefits ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$1 500 plan coverage limit for comprehensive dental benefits every year. | |||||
30% of the cost for preventive dental services. | |||||
55% to 75% of the cost for comprehensive dental services. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$13.20 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
** Extra Benefits ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. | |||||
30% of the cost for preventive dental services. | |||||
55% of the cost for comprehensive dental services. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$13.20 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
** Additional Benefits ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. | |||||
30% of the cost for preventive dental services. | |||||
55% of the cost for comprehensive dental services. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 3 - MyOption Points of Caregiving: | |||||
$20 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
** Important Information ** | |||||
Package: 3 - MyOption Points of Caregiving: | |||||
$20 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
|