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2011 Medicare Advantage Plan Benefit Details for the Humana Gold Choice H8145-024 (PFFS) - H8145-024-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Choice H8145-024 (PFFS)
Location:Shelby, Kentucky     Click to see other locations
Plan ID:H8145 - 024 - 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
Email a copy of the Humana Gold Choice H8145-024 (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$49.00 (see Plan Premium Details below)
Annual 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 (H8145 - 024):less than 10 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
$49.00 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).
$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.
0% to 20% of the cost for Part B drugs out-of-network.
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.
$0 copay for routine exams.
Vision Services
  • 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • 0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • 0% of the cost for up to 1 pair(s) of glasses every year
  • 0% of the cost for up to 1 pair(s) of contacts every year
    • $100 plan coverage limit for eye wear every year.
    0% to 20% of the cost for eye exams.
    $35 copay for eye exams.
    20% of the cost for eye wear.
    $0 copay for eye wear.
    Dental Services
    20% of the cost for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every year
  • $0 copay for up to 1 cleaning(s) every year
  • $0 copay for up to 1 dental x-ray(s) every year
    • Plan offers additional comprehensive dental benefits.
    50% of the cost for preventive dental benefits.
    20% of the cost for comprehensive dental benefits.
    50% of the cost for comprehensive dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $49.00 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).
    $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')
    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
    For each SNF stay:
    Days 1 - 20: $0 copay per SNF day
    Days 21 - 100: $137.50 copay per SNF day
    Home Health Care
    $0 copay for each Medicare-covered home health visit.
    $0 copay for home health visits.
    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 in-area network urgent care Medicare-covered visit.
    20% of the cost for each specialist visit for Medicare-covered benefits.
    20% for each primary care doctor visit.
    20% for each specialist visit.
    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.
    20% of the cost for chiropractic benefits.
    Podiatry Services
    20% of the cost for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    20% of the cost for podiatry benefits.
    Outpatient Mental Health Care
    20% of the cost for each Medicare-covered individual or group therapy visit.
    20% of the cost for Mental Health benefits.
    20% of the cost for Mental Health benefits with a psychiatrist.
    Outpatient Substance Abuse Care
    20% of the cost for Medicare-covered individual or group visits.
    20% of the cost for outpatient substance abuse benefits.
    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.
    20% of the cost for ambulatory surgical center benefits.
    20% of the cost for outpatient hospital facility benefits.
    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.
    20% of the cost for Occupational Therapy benefits.
    20% of the cost for Physical and/or Speech and Language Therapy visits.
    20% of the cost for 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.
    20% of the cost for prosthetic devices.
    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.
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    20% of the cost for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement.
    $0 copay for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    $0 copay for colorectal screenings.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    $0 copay for immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
    $0 copay for pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for Medicare-covered prostate cancer screening.
    $0 copay for prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    20% of the cost for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    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.
    0% to 20% of the cost for Part B drugs out-of-network.
    This plan does not offer prescription drug coverage.
    Dental Services
    20% of the cost for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every year
  • $0 copay for up to 1 cleaning(s) every year
  • $0 copay for up to 1 dental x-ray(s) every year
    • Plan offers additional comprehensive dental benefits.
    50% of the cost for preventive dental benefits.
    20% of the cost for comprehensive dental benefits.
    50% of the cost for comprehensive dental benefits.
    Hearing Services
    In general routine hearing exams and hearing aids not covered.
  • 20% of the cost for Medicare-covered diagnostic hearing exams
    • 20% of the cost for hearing exams.
    Vision Services
  • 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • 0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • 0% of the cost for up to 1 pair(s) of glasses every year
  • 0% of the cost for up to 1 pair(s) of contacts every year
    • $100 plan coverage limit for eye wear every year.
    0% to 20% of the cost for eye exams.
    $35 copay for eye exams.
    20% of the cost for eye wear.
    $0 copay for eye wear.
    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.
    $0 copay for routine exams.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Additional Smoking Cessation
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • $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.
    $0 copay for Health and Wellness services.
    Transportation
    This plan does not cover routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - MyOption Enhanced Dental PPO:
    $20 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    ** Extra Benefits **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • $0 copay for up to 2 cleaning(s) every year
  • $0 copay for up to 2 oral exam(s) every year
  • $0 copay for up to 1 dental x-ray(s) every year
    • $1 500 plan coverage limit for comprehensive dental benefits every year.
    50% of the cost for preventive dental services.
    50% to 75% of the cost for comprehensive dental services.
    ** Important Information **
    Premium and Other Important Information
    Package: 1 - MyOption Enhanced Dental PPO:
    $20 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    ** Additional Benefits **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • $0 copay for up to 2 cleaning(s) every year
  • $0 copay for up to 2 oral exam(s) every year
  • $0 copay for up to 1 dental x-ray(s) every year
    • $1 500 plan coverage limit for comprehensive dental benefits every year.
    50% of the cost for preventive dental services.
    50% to 75% of the cost for comprehensive dental services.
    ** Cost **
    Premium and Other Important Information
    Package: 2 - MyOption Points of Caregiving:
    $20 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Other 1
    ** Important Information **
    Package: 2 - MyOption Points of Caregiving:
    $20 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Other 1




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