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2020 Medicare Advantage Plan Benefit Details for the HumanaChoice R4182-001 (Regional PPO) - R4182-001-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Medicare Advantage Plan Details
Medicare Plan Name:HumanaChoice R4182-001 (Regional PPO)
Location:Hopkins, Texas     Click to see other locations
Plan ID:R4182 - 001 - 0     Click to see other plans
Member Services:
— 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 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 Hopkins, Texas:33 members
Number of Members enrolled in this plan in (R4182 - 001):5,106 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: 3 out of 5 Stars.
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $975 annual deductible
• Other health plan deductibles: In-network: No
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
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $15 copay per visit
• Primary Out-of-network: 30% coinsurance per visit
• Specialist In-network: $40 copay per visit
• Specialist Out-of-network: 30% coinsurance per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $0-50 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization required)
• Lab services In-network: $0-50 copay (authorization required)
• Lab services Out-of-network: 30% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $40-295 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required)
• Outpatient x-rays In-network: $15-50 copay (authorization required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $15-40 copay or 30% coinsurance per visit (always covered)
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 (authorization required)
• Out-of-network: 30% per stay (authorization required)
Outpatient hospital coverage
• In-network: $40-295 copay per visit (authorization required)
• Out-of-network: 30% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20
$172 per day for days 21 through 100 (authorization required)
• Out-of-network: 30% per stay (authorization required)
Preventive care
• In-network: $0 copay
• Out-of-network: $0 copay or 30-50% coinsurance
Ground ambulance
• In-network: $265 copay
• Out-of-network: $265 copay
Rehabilitation services
• Occupational therapy visit In-network: $25 copay (authorization required)
• Occupational therapy visit Out-of-network: 30% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit In-network: $25 copay (authorization required)
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric In-network: $295 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 30% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization required)
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization required)
• Outpatient group therapy visit In-network: $40 copay (authorization required)
• Outpatient group therapy visit Out-of-network: 30% coinsurance (authorization required)
• Outpatient individual therapy visit In-network: $40 copay (authorization required)
• Outpatient individual therapy visit Out-of-network: 30% coinsurance (authorization required)
Opioid treatment program services
• In-network: $35.00-$50.00 copay (authorization required)
• Out-of-network: 30% coinsurance (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 15% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 15% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 20% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay or 10-20% coinsurance per item (authorization required)
• Diabetes supplies Out-of-network: 20% coinsurance per item (authorization required)
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam In-network: $40 copay (authorization required)
• Hearing exam Out-of-network: 30% coinsurance (authorization required)
• Fitting/evaluation In-network: $0 copay (limits apply, authorization required)
• Fitting/evaluation Out-of-network: $0 copay (limits apply, authorization required)
• Hearing aids In-network: $399-699 copay (limits apply)
• Hearing aids Out-of-network: $399-699 copay (limits apply)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: 50% coinsurance (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: 50% coinsurance (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: 50% coinsurance (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services In-network: 50% coinsurance (limits apply, authorization required)
• Restorative services Out-of-network: 55% coinsurance (limits apply, authorization required)
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions In-network: 50% coinsurance (limits apply, authorization required)
• Extractions Out-of-network: 55% coinsurance (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply, authorization required)
• Routine eye exam Out-of-network: $0 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply, authorization required)
• Contact lenses Out-of-network: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply, authorization required)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Not covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $40 copay (authorization required)
• Foot exams and treatment Out-of-network: 30% coinsurance (authorization required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 20-30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 20-30% coinsurance (authorization required)
Package #1
• Monthly Premium: $15.00
• Deductible:
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Not covered
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered




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