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2019 Medicare Advantage Plan Benefit Details for the HumanaChoice R4182-001 (Regional PPO) - R4182-001-0

2019 Medicare Advantage Plan Details
Medicare Plan Name:HumanaChoice R4182-001 (Regional PPO)
Location:Fayette, Texas
Plan ID:R4182 - 001 - 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 R4182-001 (Regional PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00
Annual Deductible:no drug coverage
Health Plan Type:Regional PPO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,700
Number of Members enrolled in this plan in Fayette, Texas:29 members
Number of Members enrolled in this plan in (R4182 - 001):5,564 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
Customer Service Rating: 5 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
• $975 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6,700 In and Out-of-network
$5,700 In-network
Optional supplemental benefits
• Yes
Other health plan deductibles?
In-Network:  No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
In-Network:  No
Inpatient hospital coverage
In-Network:  $295 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Outpatient hospital coverage
In-Network:  $295 per visit
Preventive care
In-Network:  $0 copay
Inpatient hospital coverage
Out-of-Network:  30% per stay
Outpatient hospital coverage
Out-of-Network:  30% per visit
Preventive care
Out-of-Network:  $0 or 30-50%
Doctor visits
Primary:  In-Network:  $15 per visit
Primary:  Out-of-Network:  30% per visit
Specialist:  In-Network:  $35 per visit
Specialist:  Out-of-Network:  30% per visit
Emergency care/Urgent care
Emergency:  $90 per visit (always covered)
Urgent care:  $15-35 or 30% per visit (always covered)
• Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Skilled Nursing Facility
In-Network:  $0 per day for days 1 through 20
$172 per day for days 21 through 100
Ground ambulance
In-Network:  $265
Skilled Nursing Facility
Out-of-Network:  30% per stay
Ground ambulance
Out-of-Network:  $265
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:  $295 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital - psychiatric:  Out-of-Network:  30% per stay
Outpatient group therapy visit with a psychiatrist:  In-Network:  $35
Outpatient group therapy visit with a psychiatrist:  Out-of-Network:  30%
Outpatient individual therapy visit with a psychiatrist:  In-Network:  $35
Outpatient individual therapy visit with a psychiatrist:  Out-of-Network:  30%
Outpatient group therapy visit:  In-Network:  $35
Outpatient group therapy visit:  Out-of-Network:  30%
Outpatient individual therapy visit:  In-Network:  $35
Outpatient individual therapy visit:  Out-of-Network:  30%
Rehabilitation services
Occupational therapy visit:  In-Network:  $25
Occupational therapy visit:  Out-of-Network:  30%
Physical therapy and speech and language therapy visit:  In-Network:  $25
Physical therapy and speech and language therapy visit:  Out-of-Network:  30%
Foot care (podiatry services)
Foot exams and treatment:  In-Network:  $35
Foot exams and treatment:  Out-of-Network:  30%
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:  20% per item
Prosthetics (e.g., braces, artificial limbs):  In-Network:  15% per item
Prosthetics (e.g., braces, artificial limbs):  Out-of-Network:  20% per item
Diabetes supplies:  In-Network:  $0 or 10-20% per item
Diabetes supplies:  Out-of-Network:  20% per item
Medicare Part B drugs
Chemotherapy:  In-Network:  20%
Chemotherapy:  Out-of-Network:  20-30%
Other Part B drugs:  In-Network:  20%
Other Part B drugs:  Out-of-Network:  20-30%
** Benefits Services **
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:  In-Network:  $0-50
Diagnostic tests and procedures:  Out-of-Network:  30%
Lab services:  In-Network:  $0-50
Lab services:  Out-of-Network:  30%
Diagnostic radiology services (e.g., MRI):  In-Network:  $35-295
Diagnostic radiology services (e.g., MRI):  Out-of-Network:  30%
Outpatient x-rays:  In-Network:  $15-50
Outpatient x-rays:  Out-of-Network:  30%
Hearing exam:  In-Network:  $35
Hearing exam:  Out-of-Network:  30%
Fitting/evaluation:  Not covered
Hearing aids - inner ear:  Not covered
Hearing aids - outer ear:  Not covered
Hearing aids - over the ear:  Not covered
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:  Not covered
Endodontics:  Not covered
Periodontics:  Not covered
Extractions:  Not covered
Prosthodontics, other oral/maxillofacial surgery, other services:  Not covered
** Optional Supplemental Benefits **
Package #1
• Wellness programs (e.g., fitness, nursing hotline)
Monthly Premium:  $15.00
Deductible:  N/A

Tips & Disclaimers
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