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HumanaChoice H5216-167 (PPO) - H5216-167-000
$72.00
Monthly Premium
HumanaChoice H5216-167 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-167-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$72.00
Monthly Premium
Minnesota 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 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 | $72.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $2,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 20% |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 20% |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $300.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $25.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125.00 Copayment for Worldwide Emergency Transportation $125.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
HumanaChoice H5216-167 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-167 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 20% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 20% |
| 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 $0.00 to $85.00 Copayment for Medicare-covered Lab Services $0.00 to $25.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $100.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $85.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 20% |
| Mental health inpatient care | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $35.00 Copayment for Medicare-covered Group Sessions $35.00 Prior Authorization Required for Outpatient Mental Health Services |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $100.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $75.00 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $35.00 to $85.00 Copayment for Medicare-covered Group Sessions $35.00 to $85.00 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50% Maximum Plan Benefit of $50.00 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $35.00 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 20% |
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: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $35.00 Copayment for Diagnostic Services $0.00
Copayment for Periodontics $0.00
Prior Authorization Required for Comprehensive Dental |
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 Vision Services: Coinsurance for Medicare Covered Eye Exams 20% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-Medicare Covered Eyewear $0.00 |
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 | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $35.00 Copayment for Routine Hearing Exams $0.00
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
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 Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 Coinsurance for Medicare Covered Medicare-covered Preventive Services 20% |
When reviewing Minnesota 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 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
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.