HumanaChoice H5216-097 (PPO) 2025 Plan Details for Macon County, Tennessee Residents
HumanaChoice H5216-097 (PPO) 2025 Plan Details for Macon County, Tennessee Residents
When selecting a Medicare Advantage plan in Macon County for 2025, it's important to compare all your options. HumanaChoice H5216-097 (PPO) is among the plans you can review side-by-side with others, ensuring you find the coverage that suits your needs. You can easily enroll online or reach out to a licensed agent for personalized guidance.
HumanaChoice H5216-097 Overview
Plan ID H5216-097-0 Overview | |
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Health Plan ID: | H5216-097-0 |
Medicare Advantage Plan Type: | Local PPO |
Plan Year: | 2024 |
Monthly Premium: | $53.00 Plus your Medicare Part B premium. |
Health Plan Deductible: | $1,000.00 |
Annual Out-of-Pocket Maximum: | $8,850 |
Part B Give Back: | $0.00/mo |
Part D Drug Plan Benefit: | Enhanced, $150.00 deductible |
Part D Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Macon County, TN |
Insured By: | Humana |
Why Choose HumanaChoice H5216-097?
HumanaChoice H5216-097 is a Medicare Advantage Prescription Drug (MAPD) Preferred Provider Organization (PPO) plan offering flexibility and comprehensive healthcare coverage. With a monthly premium of $53.00, this plan provides all the benefits of Medicare Part A and Part B, along with additional services like prescription drug coverage. The annual Part D deductible is $150.00. As a PPO plan, you have the option to see providers both in and out of the plan’s network, though using in-network providers typically results in lower costs.
One of the valuable features of HumanaChoice H5216-097 is its protection against high medical expenses. The annual maximum out-of-pocket (MOOP) limit is $8,850, ensuring that once you reach this amount, the plan covers 100% of your in-network healthcare costs for the rest of the year. This makes HumanaChoice H5216-097 a flexible and reliable choice for those seeking comprehensive coverage with the freedom to choose their healthcare providers.
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Cost-Sharing Overview
With HumanaChoice H5216-097, you'll have cost-sharing expenses, which are the out-of-pocket costs for approved healthcare services. The table below provides a summary of the typical in-network out-of-pocket costs associated with plan H5216-097-0.
Service | Enrollee Cost |
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Doctor's Office Visit (In-Network) | |
Primary: | $20 Copay |
Specialist: | $45 Copay |
Wellness & Preventive Programs: | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot Exams and Treatments (Medicare-covered): | $45 Copay Prior Authorization Required |
Routine Foot Care: | Not Covered |
Chiropractic Treatment (In-Network) | |
Medicare-covered chiropractic: | $15 Copay Prior Authorization Required |
Routine chiropractic: | Not Covered |
Emergency and Urgent Care | |
Emergency room care: | $100 Copay |
Urgent care: | $45 Copay |
Ground ambulance: | $300 Copay |
Inpatient hospital care: | $325.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
Outpatient hospital care: | $300 Copay Prior Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy: | $40 Copay |
Outpatient group therapy: | $40 Copay |
Inpatient psychiatric hospital care: | $325.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy: | $40 Copay |
Outpatient individual therapy: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy: | $20 Copay Prior Authorization Required |
Occupational therapy: | $20 Copay Prior Authorization Required |
Medical Equipment and Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging (In-Network) | |
Diagnostic radiology services: | $300 Copay Prior Authorization Required |
Lab services: | $45 Copay Prior Authorization Required |
Outpatient x-rays: | $125 Copay Prior Authorization Required |
Diagnostic tests and procedures: | $90 Copay Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Most preventive services are covered 100% by HumanaChoice H5216-097 as a Part B benefit.
Supplemental Benefits
Here’s an overview of the additional benefits that Humana offers with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Prior Authorization Required, Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay Prior Authorization Required |
Vision | Maximum vision benefit: | $150.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay Prior Authorization Required |
Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Part D Prescription Drug Costs & Benefits
HumanaChoice H5216-097 includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
While the prescription drug plan (Part D) premium is included in the overall plan cost, some plans may have additional costs or provide assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security program that assists individuals with limited income and resources in reducing or eliminating Part D expenses.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $53.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $53.00 |
Part D Premium with Full LIS Assistance: | $12.30 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $150.00. You must pay this amount at the pharmacy before Humana begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, HumanaChoice H5216-097 has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | N/A | $0.00 copay (deductible does not apply) |
2 (Generic) | N/A | $10.00 copay |
3 (Preferred Brand) | N/A | $47.00 copay |
4 (Non-Preferred Drug) | N/A | $97.00 copay |
5 (Specialty Tier) | N/A | 30% |
How CMS Star Ratings Guide Your Choice
The Centers for Medicare & Medicaid Services (CMS) reviews and rates Medicare Advantage (Part C) and drug plans (Part D) annually, using a 5-star system to measure aspects such as member satisfaction, preventive services, and management of chronic conditions.
Higher star ratings generally indicate better plan performance, which can be a useful factor to consider when deciding on a plan that aligns with your healthcare goals and preferences.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Eligibility Requirements for HumanaChoice H5216-097
You are eligible to enroll in HumanaChoice H5216-097 if you meet the following conditions:
- You qualify for Medicare Part A and Part B.
- You live in the plan’s service area.
- You do not have End-Stage Renal Disease (ESRD), with some exceptions.
If these criteria describe your situation, you’re eligible to sign up for HumanaChoice H5216-097 and take advantage of its full range of benefits.
When Can I Enroll in HumanaChoice H5216-097?
Understanding the right time to enroll in HumanaChoice H5216-097 is crucial. Here are the key enrollment periods:
- Initial Enrollment Period (IEP): Your first opportunity to enroll in Medicare starts three months before your 65th birthday and lasts until three months after your birthday month.
- Annual Enrollment Period (AEP): Occurring annually from October 15 to December 7, the AEP allows you to enroll in, switch, or drop a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31 each year, the MA OEP gives you the chance to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing other coverage, may make you eligible for a SEP, allowing you to adjust your plan outside the usual periods.
Not sure when to enroll? Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711) to speak with a licensed insurance agent who can guide you through your options.
How to Enroll in HumanaChoice H5216-097
Joining HumanaChoice H5216-097 is straightforward. Here are the steps you can take:
- Online: Use our online enrollment partner's Secure Online Enrollment Form to sign up.
- By Phone: Reach out to HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711). A licensed insurance agent will help you with the enrollment process and answer any questions you might have.
- Through Medicare.gov: Enroll directly through the official Medicare website. Visit Medicare.gov, log in or create an account, and follow the steps to join HumanaChoice H5216-097.
- Direct Enrollment: You can also choose to enroll directly with HumanaChoice H5216-097. The contact information can be found below in the "Contact" section.
Make sure you enroll during the appropriate period to activate your coverage as soon as possible.
Contact Humana
Website: | http://www.humana.com/medicare |
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Formulary: | https://www.humana.com/pharmacy/ |
Pharmacy: | Humana Pharmacy Page |
New Members: | (800)833-2364 |
TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, you can do so on the Social Security Administration website. For more information about the Medicare Part C program, visit the official Medicare website or call 1-800-MEDICARE.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
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