HumanaChoice Giveback H5216-371 (PPO)
HumanaChoice Giveback H5216-371 (PPO) H5216-371 Plan Details
HumanaChoice Giveback H5216-371 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-371
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
HumanaChoice Giveback H5216-371 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-371
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
HumanaChoice Giveback H5216-371 (PPO) H5216-371 Plan Details
HumanaChoice Giveback H5216-371 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-371
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $6500 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $35 Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $55 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $375 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: $495 per day for days 1 to 20 $0 per day for days 21 to 90 |
| Urgent Care | Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | Copayment for Emergency Care $125 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 $125 Copayment for Worldwide Emergency Transportation $125 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Copayment for Air Ambulance Services $630 Prior Authorization Required for Air Ambulance Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $315 Copayment for Medicare Covered Ambulance Services - Air $630 |
Health Care Services and Medical Supplies
HumanaChoice Giveback H5216-371 (PPO) 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 $15 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Medicare Covered Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $50 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 40% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 10% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
| 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 $55 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0 to $55 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $0 Coumadin Clinic Svcs - OPH20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$55 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 $375 Copayment for Medicare-covered Therapeutic Radiological Services $75 Copayment for Medicare-covered X-Ray Services $0 to $55 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $55 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% to 50% Copayment for Medicare Covered Lab Services $0 to $55 Coinsurance for Medicare Covered Lab Services 40% Copayment for Medicare Covered Diagnostic Radiological Services $0 to $495 Copayment for Medicare Covered Therapeutic Radiological Services $150 Copayment for Medicare Covered Outpatient X-Ray Services $0 to $55 Coinsurance for Medicare Covered Outpatient X-Ray Services 40% $0 Coumadin Clinic Svcs - OPH20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $322 per day for days 1 to 6 $0 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Psychiatric Hospital Services: $495 per day for days 1 to 20 $0 per day for days 21 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Out-of-Network: Medicare Covered Mental Health Services: Copayment for Medicare Covered Individual Sessions $50 Copayment for Medicare Covered Group Sessions $50 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $385 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$30 Mental Health - OPH$385 Surgery Svcs - OPH$50 Wound Care - OPH_ Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $375 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $300 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$300 Surgery Svcs - ASC_ Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $50 to $495 Coinsurance for Medicare Covered Outpatient Hospital Services 40% Copayment for Medicare Covered Ambulatory Surgical Center Services $395 Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% $0 Diag Colonoscopy - OPH$30 Mental Health - OPH$385 Surgery Svcs - OPH$50 Wound Care - OPH_ |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $50 Copayment for Medicare Covered Group Sessions $50 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $55 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $214 per day for days 21 to 51 $0 per day for days 52 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Skilled Nursing Facility Services: $250 per day for days 1 to 39 $0 per day for days 40 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Plan covers up to $1000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire. Your benefit can be used for most dental treatments such as: Preventive dental services, such as exams, routine cleanings, etc. Basic dental services, such as fillings, extractions, etc. Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc. Frequency limits may apply. Note: The allowance cannot be used on fluoride, cosmetic services and implants.Out of NetworkPlan covers up to $1000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire. Your benefit can be used for most dental treatments such as: Preventive dental services, such as exams, routine cleanings, etc. Basic dental services, such as fillings, extractions, etc. Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc. Frequency limits may apply. Note: The allowance cannot be used on fluoride, cosmetic services and implants. 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 from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $35 Copayment for Routine Eye Exams $0
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 $50 less than the PLUS network. Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $55 Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0 |
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 $35 Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $299 to $599
Prior authorization required Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $55 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| 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 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% |
