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HumanaChoice H5216-215 (PPO) - H5216-215-000
$0.00
Monthly Premium
HumanaChoice H5216-215 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-215-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Illinois 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 Illinois 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 | $0.00 |
| Out-of-pocket maximum | $5,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient hospital care | In-Network: Acute Hospital Services: $320.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $60.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $120.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
HumanaChoice H5216-215 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-215 (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 $20.00 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 50% |
| 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 $105.00 Copayment for Medicare-covered Lab Services $0.00 to $40.00 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 $320.00 Copayment for Medicare-covered Therapeutic Radiological Services $45.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $125.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $320.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40.00 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $10.00 per day for days 1 to 20 $203.00 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 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 complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 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, fluoride treatment, 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 amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $1,500 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits. Out of Network: $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 complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 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, fluoride treatment, 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 amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $1,500 combined maximum benefit coverage amount per year for all 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: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0.00 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 | Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 50% Coinsurance for Non-Medicare Covered Hearing Aids 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 Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
When reviewing Illinois 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 Illinois that offer similar benefits at similar or lower prices than the plan above. Call 1-877-822-4889 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Illinois Counties Served
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