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HumanaChoice H5216-092 (PPO) - H5216-092-000
$48.00
Monthly Premium
HumanaChoice H5216-092 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-092-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$48.00
Monthly Premium
Minnesota, North Dakota, and South Dakota 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 extra benefits Original Medicare doesn’t cover.
Learn more about Minnesota, North Dakota, and South Dakota Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $48.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $20 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent care | Urgent Care: Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $110 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 $110 Copayment for Worldwide Emergency Transportation $110 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
HumanaChoice H5216-092 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-092 (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: Coinsurance for Medicare-covered Chiropractic Services 20% 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 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| 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 to $50 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0 Coinsurance for Medicare-covered Lab Services 20% Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services 20% OP Diag Proc & Tests - OPH$20 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $20 to $50 Coinsurance for Medicare-covered X-Ray Services 20% |
| Home health care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50% |
| Mental health outpatient care | Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy - OPH20% Mental Health - OPH20% Surgery Svcs - OPH$50 Wound Care - OPH_ |
| Outpatient substance abuse care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 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 | $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year.Out of Network$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year. 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: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 50% |
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: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% |
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 Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-092 (PPO) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Minnesota, North Dakota, and South Dakota 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 Minnesota, North Dakota, and South Dakota 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 |
Minnesota Counties Served
- Aitkin
- Anoka
- Becker
- Beltrami
- Benton
- Blue Earth
- Brown
- Carlton
- Carver
- Clay
- Clearwater
- Crow Wing
- Dakota
- Deuel
- Dodge
- Faribault
- Fillmore
- Freeborn
- Hennepin
- Houston
- Hubbard
- Isanti
- Itasca
- Kanabec
- Kittson
- Lac Qui Parle
- Lake
- Lake Of The Woods
- Le Sueur
- Lincoln
- Lyon
- Mahnomen
- Marshall
- Martin
- Mcleod
- Meeker
- Morrison
- Mower
- Nicollet
- Nobles
- Norman
- Otter Tail
- Pennington
- Pipestone
- Polk
- Ramsey
- Red Lake
- Renville
- Rock
- Roseau
- Saint Louis
- Scott
- Steele
- Todd
- Wadena
- Waseca
- Washington
- Winona
- Wright
North Dakota Counties Served
South Dakota Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.