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Humana DaVita Kidney Care (PPO C-SNP) - H7617-137-000
$0.00
Monthly Premium
Humana DaVita Kidney Care (PPO C-SNP) is a PPO C-SNP Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H7617-137-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Texas Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Texas Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $9,850.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 35% |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 20% Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $2241 |
| Urgent care | Urgent Care: Coinsurance for Urgent Care 20% Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $0 |
| Ambulance transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Humana DaVita Kidney Care (PPO C-SNP) covers a range of additional benefits. Learn more about Humana DaVita Kidney Care (PPO C-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 20% Copayment for Routine Care $0
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services 20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC20% OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC20% Sleep Study (Home Based) - Mbr's Home Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 Coinsurance for Medicare-covered X-Ray Services 20% |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $2091 |
| Mental health outpatient care | Out-of-Network: Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 35% Coinsurance for Medicare Covered Group Sessions 35% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $20 Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$20 Mental Health - OPH20% Surgery Svcs - OPH20% Wound Care - OPH Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Coinsurance for Ambulatory Surgical Center Services 20% Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC20% Surgery Svcs - ASC |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | In-Network: $150 monthly allowance on a prepaid spending card. All plan members receive this amount to buy approved over the counter (OTC) health and wellness products at participating retailers or through the plan’s approved OTC mail order vendor. Plus, members may also use this money for eligible groceries, utilities, rent, and more if they have certain qualifying chronic condition(s) and meet other program criteria. Any unused amount rolls over each month and expires at the end of the plan year or upon disenrollment, whichever occurs first. Out-of-Network: 95% coinsurance. Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 35% |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $221 per day for days 21 to 100 |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: $0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. $0 copayment for crown recementation up to 1 every 2 years. $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. $0 copayment for bridges-pontic, panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bridges-crown up to 2 every 5 years. $0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime. $0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. $0 copayment for bitewing x-rays, bridge recementation, scaling for moderate inflammation up to 1 per year. $0 copayment for emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for intraoral x-rays up to 6 per year. $0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $1,250 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Out-of-Network: $0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. $0 copayment for crown recementation up to 1 every 2 years. $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. $0 copayment for bridges-pontic, panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bridges-crown up to 2 every 5 years. $0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime. $0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. $0 copayment for bitewing x-rays, bridge recementation, scaling for moderate inflammation up to 1 per year. $0 copayment for emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for intraoral x-rays up to 6 per year. $0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $1,250 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 Coinsurance for Medicare Covered Eye Exams 35% Coinsurance for Medicare Covered Eyewear 50% $0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 35% |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
When reviewing Texas Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Texas that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Texas Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.