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2019 Medicare Advantage Plan Benefit Details for the HumanaChoice H5216-140 (PPO) - H5216-140-0

2019 Medicare Advantage Plan Details
Medicare Plan Name:HumanaChoice H5216-140 (PPO)
Location:Douglas, Kansas
Plan ID:H5216 - 140 - 0     Click to see other plans
Member Services:
— This plan information is for research purposes only. —
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Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Email a copy of the HumanaChoice H5216-140 (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00
Annual Deductible:no drug coverage
Health Plan Type:Local PPO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$4,900
Plan Offers Mail Order?n/a
Number of Members enrolled in this plan in Douglas, Kansas:25 members
Number of Members enrolled in this plan in Kansas:789 members
Number of Members enrolled in this plan in (H5216 - 140):6,051 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
Customer Service Rating: 4 out of 5 Stars.
Member Experience Rating: 4 out of 5 Stars.
Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible $0
Other health plan deductibles? In-Network:  No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $10,000 In and Out-of-network
$4,900 In-network
Optional supplemental benefits Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? In-Network:  No
Inpatient hospital coverage In-Network:  $360 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
  Out-of-Network:  40% per stay
Outpatient hospital coverage In-Network:  25% per visit
  Out-of-Network:  40% per visit
Doctor visits Primary:  In-Network:  $0 copay
  Primary:  Out-of-Network:  40% per visit
  Specialist:  In-Network:  $35 per visit
  Specialist:  Out-of-Network:  40% per visit
Preventive care In-Network:  $0 copay
  Out-of-Network:  $0 or 40%
Emergency care/Urgent care Emergency:  $90 per visit (always covered)
  Urgent care:  $0-35 or 40% per visit (always covered)
Vision Routine eye exam:  In-Network:  $0 copay
  Routine eye exam:  Out-of-Network:  $0 copay
  Other:  Not covered
  Contact lenses:  In-Network:  $0 copay
  Contact lenses:  Out-of-Network:  $0 copay
  Eyeglasses (frames and lenses):  In-Network:  $0 copay
  Eyeglasses (frames and lenses):  Out-of-Network:  $0 copay
  Eyeglass frames:  Not covered
  Eyeglass lenses:  Not covered
  Upgrades:  Not covered
Mental health services Inpatient hospital - psychiatric:  In-Network:  $318 per day for days 1 through 5
$0 per day for days 6 through 90
  Inpatient hospital - psychiatric:  Out-of-Network:  40% per stay
  Outpatient group therapy visit with a psychiatrist:  In-Network:  $35
  Outpatient group therapy visit with a psychiatrist:  Out-of-Network:  40%
  Outpatient individual therapy visit with a psychiatrist:  In-Network:  $35
  Outpatient individual therapy visit with a psychiatrist:  Out-of-Network:  40%
  Outpatient group therapy visit:  In-Network:  $35
  Outpatient group therapy visit:  Out-of-Network:  40%
  Outpatient individual therapy visit:  In-Network:  $35
  Outpatient individual therapy visit:  Out-of-Network:  40%
Skilled Nursing Facility In-Network:  $0 per day for days 1 through 20
$167.50 per day for days 21 through 100
  Out-of-Network:  40% per stay
Rehabilitation services Occupational therapy visit:  In-Network:  $30-40
  Occupational therapy visit:  Out-of-Network:  40%
  Physical therapy and speech and language therapy visit:  In-Network:  $30-40
  Physical therapy and speech and language therapy visit:  Out-of-Network:  40%
Ground ambulance In-Network:  $265
  Out-of-Network:  $265
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment:  In-Network:  $35
  Foot exams and treatment:  Out-of-Network:  40%
  Routine foot care:  Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen):  In-Network:  15% per item
  Durable medical equipment (e.g., wheelchairs, oxygen):  Out-of-Network:  15% per item
  Prosthetics (e.g., braces, artificial limbs):  In-Network:  20% per item
  Prosthetics (e.g., braces, artificial limbs):  Out-of-Network:  40% per item
  Diabetes supplies:  In-Network:  $0 or 10-20% per item
  Diabetes supplies:  Out-of-Network:  40% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy:  In-Network:  20%
  Chemotherapy:  Out-of-Network:  20-40%
  Other Part B drugs:  In-Network:  20%
  Other Part B drugs:  Out-of-Network:  20-40%
** Benefits Services **
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures:  In-Network:  $0-50 or 25%
  Diagnostic tests and procedures:  Out-of-Network:  40%
  Lab services:  In-Network:  $0-30 or 25%
  Lab services:  Out-of-Network:  40%
  Diagnostic radiology services (e.g., MRI):  In-Network:  $35-180 or 20-25%
  Diagnostic radiology services (e.g., MRI):  Out-of-Network:  40%
  Outpatient x-rays:  In-Network:  $0-35 or 20-25%
  Outpatient x-rays:  Out-of-Network:  40%
Hearing Hearing exam:  In-Network:  $35
  Hearing exam:  Out-of-Network:  40%
  Fitting/evaluation:  In-Network:  $0 copay
  Fitting/evaluation:  Out-of-Network:  $0 copay
  Hearing aids:  In-Network:  $399-699
  Hearing aids:  Out-of-Network:  $399-699
Preventive dental Oral exam:  In-Network:  $0 copay
  Oral exam:  Out-of-Network:  50%
  Cleaning:  In-Network:  $0 copay
  Cleaning:  Out-of-Network:  50%
  Fluoride treatment:  Not covered
  Dental x-ray(s):  In-Network:  $0 copay
  Dental x-ray(s):  Out-of-Network:  50%
Comprehensive dental Non-routine services:  Not covered
  Diagnostic services:  Not covered
  Restorative services:  In-Network:  50%
  Restorative services:  Out-of-Network:  55%
  Endodontics:  Not covered
  Periodontics:  Not covered
  Extractions:  In-Network:  50%
  Extractions:  Out-of-Network:  55%
  Prosthodontics, other oral/maxillofacial surgery, other services:  Not covered
** Optional Supplemental Benefits **
Package #1 Comprehensive dental, Preventive dental
  Monthly Premium:  $19.90
  Deductible:  N/A

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