2021 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Humana Gold Choice H8145-055 (PFFS) | ||||
Location: | Randolph, West Virginia Click to see other locations | ||||
Plan ID: | H8145 - 055 - 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 |
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Email a copy of the Humana Gold Choice H8145-055 (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $7.00 | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | PFFS * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||
Number of Members enrolled in this plan in Randolph, West Virginia: | less than 10 members | ||||
Number of Members enrolled in this plan in West Virginia: | 21 members | ||||
Number of Members enrolled in this plan in (H8145 - 055): | 1,508 members | ||||
Plan’s Summary Star Rating: | 3.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $7.00 | |||||
• Health plan premium: $7 | |||||
• Drug plan premium: $0 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• 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 | |||||
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: $15 copay per visit | |||||
• Specialist In-network: $45 copay per visit | |||||
• Specialist Out-of-network: $45 copay per visit | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures In-network: $0-105 copay | |||||
• Diagnostic tests and procedures Out-of-network: $0-105 copay | |||||
• Lab services In-network: $0-40 copay | |||||
• Lab services Out-of-network: $0-105 copay | |||||
• Diagnostic radiology services (e.g., MRI) In-network: $45-390 copay | |||||
• Diagnostic radiology services (e.g., MRI) Out-of-network: $45-390 copay | |||||
• Outpatient x-rays In-network: $15-100 copay | |||||
• Outpatient x-rays Out-of-network: $15-100 copay | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $15-45 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• In-network: $390 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: $390 per day for days 1 through 5 $0 per day for days 6 through 90 | |||||
Outpatient hospital coverage | |||||
• In-network: $45-390 copay per visit | |||||
• Out-of-network: $45-390 copay per visit | |||||
Skilled Nursing Facility | |||||
• In-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 | |||||
• Out-of-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 | |||||
Preventive care | |||||
• In-network: $0 copay | |||||
• Out-of-network: $0 copay | |||||
Ground ambulance | |||||
• In-network: $270 copay | |||||
• Out-of-network: $270 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit In-network: $20-40 copay | |||||
• Occupational therapy visit Out-of-network: $20-40 copay | |||||
• Physical therapy and speech and language therapy visit In-network: $20-40 copay | |||||
• Physical therapy and speech and language therapy visit Out-of-network: $20-40 copay | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric In-network: $390 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
• Inpatient hospital - psychiatric Out-of-network: $390 per day for days 1 through 4 $0 per day for days 5 through 90 | |||||
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay | |||||
• Outpatient group therapy visit with a psychiatrist Out-of-network: $40-100 copay | |||||
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay | |||||
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $40-100 copay | |||||
• Outpatient group therapy visit In-network: $40 copay | |||||
• Outpatient group therapy visit Out-of-network: $40-100 copay | |||||
• Outpatient individual therapy visit In-network: $40 copay | |||||
• Outpatient individual therapy visit Out-of-network: $40-100 copay | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 20% coinsurance per item | |||||
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item | |||||
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 20% coinsurance per item | |||||
• Diabetes supplies In-network: $0 copay or 10-20% coinsurance per item | |||||
• Diabetes supplies Out-of-network: 10-20% coinsurance per item | |||||
Hearing | |||||
• Hearing exam In-network: $45 copay | |||||
• Hearing exam Out-of-network: $45 copay | |||||
• 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: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
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 | |||||
Vision | |||||
• Routine eye exam: Not covered | |||||
• Other: Not covered | |||||
• Contact lenses: Not covered | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment In-network: $45 copay | |||||
• Foot exams and treatment Out-of-network: $45 copay | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Chemotherapy In-network: 20% coinsurance | |||||
• Chemotherapy Out-of-network: 20% coinsurance | |||||
• Other Part B drugs In-network: 20% coinsurance | |||||
• Other Part B drugs Out-of-network: 20% coinsurance | |||||
Package #1 | |||||
• Monthly Premium: $18.10 | |||||
• Deductible: | |||||
Package #2 | |||||
• Monthly Premium: $20.70 | |||||
• Deductible: $50.00 | |||||
Package #3 | |||||
• Monthly Premium: $21.50 | |||||
• Deductible: |