2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Humana Gold Choice H2944-197 (PFFS) | ||||
Location: | Clark, Missouri Click to see other locations | ||||
Plan ID: | H2944 - 197 - 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 H2944-197 (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (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 - 197): | 529 members | ||||
Plan’s Summary Star Rating: | 3 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 out of 5 Stars. | ||||
— 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 | |||||
$0.00 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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$162 annual deductible. Contact the plan for services that apply. | |||||
$6 700 out-of-pocket limit for 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 ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$0.00 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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$162 annual deductible. Contact the plan for services that apply. | |||||
$6 700 out-of-pocket limit for 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 | |||||
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 hospital stay. | |||||
You will not be charged additional cost sharing for professional services | |||||
For additional hospital days: | |||||
Days 91 - 150: $566 copay per day | |||||
Days 151 and beyond: $0 copay per day | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
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: $141.50 copay per day | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select 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. | |||||
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 therapy visit | |||||
20% of the cost for each Medicare-covered group therapy visit | |||||
20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist | |||||
20% of the cost for each Medicare-covered group therapy visit with a psychiatrist | |||||
20% of the cost for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
20% of the cost for Medicare-covered individual visits | |||||
20% of the cost for Medicare-covered group visits | |||||
Outpatient Services/Surgery | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
20% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
$25 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
Urgently Needed Care | |||||
Cost sharing is the same as Doctor Office Visit cost sharing. | |||||
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 | |||||
** 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 Programs and Supplies | |||||
0% of the cost for Diabetes self-management training | |||||
0% to 20% of the cost for Diabetes monitoring supplies | |||||
$10 copay for Therapeutic shoes or inserts | |||||
20% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
0% to 20% of the cost for Medicare-covered lab services | |||||
0% to 20% of the cost for Medicare-covered diagnostic procedures and tests | |||||
20% of the cost for Medicare-covered X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
0% to 20% of the cost for diagnostic procedures tests and lab services | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
20% of the cost for Medicare-covered Cardiac Rehabilitation Services | |||||
20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
20% of the cost for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
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. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
Kidney Disease and Conditions | |||||
20% of the cost for renal dialysis | |||||
0% of the cost for kidney disease education services | |||||
Outpatient 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 supplemental routine hearing exams and hearing aids not covered. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
In general supplemental routine eye exams and eye wear not covered. However this plan covers some vision benefits for an extra cost (see 'Optional Benefits'). | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
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 hospital stay. | |||||
You will not be charged additional cost sharing for professional services | |||||
For additional hospital days: | |||||
Days 91 - 150: $566 copay per day | |||||
Days 151 and beyond: $0 copay per day | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
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. | |||||
Outpatient Services/Surgery | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
20% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
0% to 20% of the cost for Medicare-covered lab services | |||||
0% to 20% of the cost for Medicare-covered diagnostic procedures and tests | |||||
20% of the cost for Medicare-covered X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
0% to 20% of the cost for diagnostic procedures tests and lab services | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$27 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 500 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$27 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 500 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% to 75% of the cost for comprehensive dental services | |||||
$1 500 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 500 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$17 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 000 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$17 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 000 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% of the cost for comprehensive dental services | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 3 - MyOption Vision: | |||||
$15 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$290 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 3 - MyOption Vision: | |||||
$15 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$290 plan coverage limit every year for these benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 4 - MyOption Plus: | |||||
$28 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Important Information ** | |||||
Package: 4 - MyOption Plus: | |||||
$28 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% of the cost for comprehensive dental services | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 5 - MyOption Fitness Well Being: | |||||
$30 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Important Information ** | |||||
Package: 5 - MyOption Fitness Well Being: | |||||
$30 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: |