Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP)
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) H0028-064 Plan Details
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-064
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$0.00
Monthly Premium
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-064
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) H0028-064 Plan Details
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-064
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $545 |
| Out of Pocket Max |
In-Network: $8800 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $0.00 per day for days 1 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Humana Gold Plus SNP-DE H0028-064 (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| 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 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Please see Evidence of Coverage for Additional Home Health Benefits Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $600.00 every year Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00
Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Prior Authorization Required for Comprehensive Dental Referral Required for Comprehensive Dental Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Referral Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Prior Authorization Required for Eyewear Referral Required for Eyewear Prior authorization required |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00
Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0.00
Prior authorization required |
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