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HumanaChoice SNP-DE H5216-420 (PPO D-SNP) - H5216-420-000
$15.30
Monthly Premium
HumanaChoice SNP-DE H5216-420 (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-420-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$15.30
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.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $15.30 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $615.00 |
| Out-of-pocket maximum | $9,250.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit 0% or 20% |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 0% or 20% Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 or $2230 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Coinsurance for Urgent Care 0% or 20% Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 or $115 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 or $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 $0 or $115 Copayment for Worldwide Emergency Transportation $0 or $115 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $0 or $335 Coinsurance for Medicare Covered Ambulance Services - Air 0% or 20% |
Health Care Services and Medical Supplies
HumanaChoice SNP-DE H5216-420 (PPO D-SNP) covers a range of additional benefits. Learn more about HumanaChoice SNP-DE H5216-420 (PPO D-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 0% or 20% Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare Covered Diabetic Supplies $0 or 0 Coinsurance for Medicare Covered Diabetic Supplies 0 or 20% Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 or 0 Coinsurance for Medicare-covered Durable Medical Equipment 0 or 20% Prior Authorization Required for Durable Medical Equipment $0 Continuous Glucose Monitor - DME Prov$0 Continuous Glucose Monitor - Pharmacy20% DME - DME Prov20% DME - Pharmacy |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 or 0 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 0 or 20% Copayment for Medicare Covered Lab Services $0 or 0 to $30 Coinsurance for Medicare Covered Lab Services 0 or 20% Copayment for Medicare Covered Diagnostic Radiological Services $0 or 0 to $335 Coinsurance for Medicare Covered Diagnostic Radiological Services 0 or 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 0% or 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 0% or 20% 20% OP Diag Proc & Tests - OPH20% OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC20% 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: Copayment for Medicare Covered Home Health $0 |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital per Stay $0 or $2080 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 or 0 Coinsurance for Medicare Covered Outpatient Hospital Services 0 or 20% Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH20% Mental Health - OPH20% Surgery Svcs - OPH20% Wound Care - OPH Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 0% or 20% Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 or 0 Coinsurance for Ambulatory Surgical Center Services 0 or 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: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | Healthy Options Allowance: $200 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. |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 0% or 20% |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 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 | $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, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for bridge recementation, bridges-pontic, complete dentures, crown recementation, 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 for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year. $0 copayment for emergency treatment for pain, 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 necessary anesthesia with covered service up to as needed with covered codes per year. $0 copayment for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. $5,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. |
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 or 0 Coinsurance for Medicare Covered Benefits 0 or 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 | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 0% or 20% Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0
|
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 |
Prescription Drug Costs and Coverage
The HumanaChoice SNP-DE H5216-420 (PPO D-SNP) offers prescription drug coverage, with an annual drug deductible of $615.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
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 1-855-861-8771 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, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.