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Humana Value Plus H5216-173 (PPO) - H5216-173-000
$6.30
Monthly Premium
Humana Value Plus H5216-173 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-173-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$6.30
Monthly Premium
Wisconsin 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 Wisconsin 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 | $6.30 |
| 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 | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 20% |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $1545 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Coinsurance for Urgent Care 30% 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 $325 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $325 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Humana Value Plus H5216-173 (PPO) covers a range of additional benefits. Learn more about Humana Value Plus H5216-173 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
| 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% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 16% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% to 50% Coinsurance for Medicare Covered Lab Services 30% to 50% Copayment for Medicare Covered Diagnostic Radiological Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% to 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 20% to 50% 20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC30% OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1395 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Coinsurance for Medicare Covered Outpatient Hospital Services 20% to 50% Copayment for Medicare Covered Ambulatory Surgical Center Services $0 Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy - OPH$35 Mental Health - OPH20% Surgery Svcs - OPH20% Wound Care - OPH |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35 Copayment for Medicare-covered Group Sessions $35 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | In-Network: $55 quarterly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider. Unused amount rolls over to the next quarter and expires at the end of the plan year. Out-of-Network: 95% coinsurance for approved over-the-counter health and wellness products up to $55 quarterly allowance amount. 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 | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 20% Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $221 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
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, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. $0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures 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, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year. $0 copayment for denture repair - broken teeth up to 2 per tooth per year. $0 copayment for adjustments to dentures, denture repair - base and framework, 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. $3,500 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, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. $0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures 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, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year. $0 copayment for denture repair - broken teeth up to 2 per tooth per year. $0 copayment for adjustments to dentures, denture repair - base and framework, 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. $3,500 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 | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Eye Exams $0
$0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $100 less than the PLUS network. |
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 20% |
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 | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Wisconsin 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 Wisconsin 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 |
Wisconsin Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.