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PUB Name: GSB0052022Summary of BenefitsHumana Group Medicare Advantage PPO PlanPPO 079/409Portico Benefit Services - Premium PlanY0040 GHHK6WJEN22 MSB079409EN22
Our service area includes specific counties within the United States, Puerto Rico and all othermajor US Territories.
Let's talk about the Humana GroupMedicare Advantage PPO Plan.Find out more about the Humana Group Medicare Advantage PPO plan – including theservices it covers – in this easy-to-use guide.The benefit information provided is a summary of what we cover and what you pay. Itdoesn't list every service that we cover or list every limitation or exclusion. For acomplete list of services we cover, refer to the "Evidence of Coverage".To be eligibleTo join the Humana Group MedicareAdvantage PPO plan, you must beentitled to Medicare Part A, beenrolled in Medicare Part B, and live inour service area.Humana Group Medicare Advantage PPO planhas a network of doctors, hospitals, and otherproviders. For more information, please callGroup Medicare Customer Care.Plan name:Humana Group Medicare AdvantagePPO planHow to reach us:A healthy partnershipMembers should call toll-free1-888-445-4788 for questions(TTY/TDD 711)Get more from your plan — with extraservices and resources provided byHumana!Call Monday – Friday, 8 a.m. - 9 p.m.Eastern Time.Or visit our website: Humana.com2022-3-Summary of Benefits
Monthly Premium, Deductible and Limits-IN-NETWORKOUT-OF-NETWORKPLAN COSTSMonthly premiumYou must keep paying yourMedicare Part B premium.For information concerning the actual premiums you will pay, pleasecontact your employer group benefits plan administrator.Medical deductibleThis plan does not have a deductible.Maximum out-of-pocketresponsibilityThe most you pay for copays,coinsurance and other costs formedical services for the year.In-Network MaximumOut-of-Pocket 0 out-of-pocket limit forMedicare-covered services. Thefollowing services do not apply tothe maximum out-of-pocket: PartD Pharmacy; COVID-19 Testing;COVID-19 Treatment; FitnessProgram; Health EducationServices; Hearing Services(Routine); Meal Benefit; OTC Drugsand Supplies; Post-DischargePersonal Home Care;Post-Discharge TransportationServices; Smoking Cessation(Additional) and the PlanPremium.If you reach the limit onout-of-pocket costs, we will paythe full cost for the rest of theyear on covered hospital andmedical services.Combined In andOut-of-Network MaximumOut-of-Pocket 0 out-of-pocket limit forMedicare-covered services.In-Network Exclusions: Part DPharmacy; COVID-19 Testing;COVID-19 Treatment; FitnessProgram; Health EducationServices; Hearing Services(Routine); Meal Benefit; OTC Drugsand Supplies; Post-DischargePersonal Home Care;Post-Discharge TransportationServices; Smoking Cessation(Additional) and the PlanPremium do not apply to thecombined maximumout-of-pocket.Out-of-Network Exclusions: Part DPharmacy; COVID-19 Testing;COVID-19 Treatment; HearingServices (Routine); WorldwideCoverage and the Plan Premiumdo not apply to the combinedmaximum out-of-pocket.Your limit for services receivedfrom in-network providers willcount toward this limit.If you reach the limit onout-of-pocket costs, we will paythe full cost for the rest of theyear on covered hospital andmedical services.Note: some services require prior authorization.2022Note: some services require prior authorization and referrals from providers.-4-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKOUT-OF-NETWORK 0 per admit 0 per admitOutpatient hospital visits 0 copay 0 copayAmbulatory surgical center 0 copay 0 copayPrimary care provider (PCP) 0 copay 0 copaySpecialists 0 copay 0 copayCovered at no costCovered at no costEmergency room 0 copay for Medicare-coveredemergency room visit(s) 0 copay for Medicare-coveredemergency room visit(s)Urgently needed servicesUrgently needed services are careprovided to treat anon-emergency, unforeseenmedical illness, injury or conditionthat requires immediate medicalattention. 0 copay 0 copayACUTE INPATIENT HOSPITAL CAREOur plan covers an unlimitednumber of days for an inpatienthospital stay. Except in anemergency, your doctor must tellthe plan that you are going to beadmitted to the hospital.OUTPATIENT HOSPITAL COVERAGEDOCTOR OFFICE VISITSPREVENTIVE CAREIncluding: Annual Wellness Visit,flu vaccine, colorectal cancer andbreast cancer screenings. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.EMERGENCY CAREDIAGNOSTIC SERVICES, LABS AND IMAGINGDiagnostic radiology 0 copay 0 copayLab services 0 copay 0 copayDiagnostic tests and procedures 0 copay 0 copayNote: some services require prior authorization.2022-5-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKOUT-OF-NETWORKOutpatient X-rays 0 copay 0 copayRadiation therapy 0 copay 0 copayMedicare-covered hearing 0 copay 0 copayRoutine hearing 50 combined in and out ofnetwork maximum benefitcoverage amount for routinehearing exams up to unlimitedevery 2 years. 3000 combined in and out ofnetwork maximum benefitcoverage amount for both hearingaid(s) (all types) up to 2 every 3years. 50 combined in and out ofnetwork maximum benefitcoverage amount for routinehearing exams up to unlimitedevery 2 years. 3000 combined in and out ofnetwork maximum benefitcoverage amount for both hearingaid(s) (all types) up to 2 every 3years.Benefits received out-of-networkare subject to any in-networkbenefit maximums, limitations,and/or exclusions. 0 copay 0 copayMedicare-covered visionservices 0 copay 0 copayMedicare-covered diabetic eyeexam 0 copay 0 copayMedicare-covered glaucomascreening 0 copay 0 copayMedicare-covered eyewear(post-cataract) 0 copay 0 copayHEARING SERVICESDENTAL SERVICESMedicare-covered dentalVISION SERVICESNote: some services require prior authorization.2022-6-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKOUT-OF-NETWORKInpatientThe inpatient hospital care limitapplies to inpatient mentalservices provided in a generalhospital. Except in an emergency,your doctor must tell the planthat you are going to beadmitted to the hospital.190 day lifetime limit in apsychiatric facility 0 per admit 0 per admitOutpatient group and individualtherapy visits 0 copay 0 copay 0 copay per day for days 1-100 0 copay per day for days 1-100 0 copay 0 copay 0 copay 0 copay 0 copay or 0% of the cost 0 copay or 0% of the cost 0 copay 0 copayMENTAL HEALTH SERVICESSKILLED NURSING FACILITYOur plan covers up to 100 days ina SNF.No 3-day hospital stay isrequired.Plan pays 0 after 100 daysPHYSICAL THERAPYAMBULANCEPer date of service regardless ofthe number of trips.Limited to Medicare-coveredtransportation.PART B PRESCRIPTION DRUGSACUPUNCTURE SERVICESMedicare-covered acupuncture20 combined In & Out-of-Networkvisit limit per plan yearYour plan allows services to bereceived by a provider licensed toperform acupuncture or byproviders meeting the OriginalMedicare provider requirements.Note: some services require prior authorization.2022-7-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKOUT-OF-NETWORK 0 copay 0 copay 0 copay 0 copayALLERGYAllergy shots & serumCHIROPRACTIC SERVICESMedicare-covered chiropracticvisit(s)COVID-19Testing and Treatment 0 copay for testing and treatment services for COVID-19DIABETES MANAGEMENT TRAINING 0 copay 0 copay 0 copay 0 copay 0 copay 0 copayDurable medical equipment(like wheelchairs or oxygen)0% of the cost0% of the costMedical supplies0% of the cost0% of the costProsthetics (artificial limbs orbraces)0% of the cost0% of the costDiabetes monitoring supplies 0 copay 0 copay 0 copay 0 copay 25 maximum benefit coverageamount per quarter (3 months)for select over-the-counter healthand wellness products.N/AOccupational and speechtherapy 0 copay 0 copayCardiac rehabilitation 0 copay 0 copayFOOT CARE (PODIATRY)Medicare-covered foot careHOME HEALTH CAREMEDICAL EQUIPMENT/SUPPLIESOUTPATIENT SUBSTANCE ABUSEOutpatient group and individualsubstance abuse treatmentvisitsOVER-THE-COUNTER ITEMS-REHABILITATION SERVICESNote: some services require prior authorization.2022-8-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKOUT-OF-NETWORKPulmonary rehabilitation 0 copay 0 copayRenal dialysis 0 copay 0 copayKidney disease educationservices 0 copay 0 copayRENAL DIALYSISTELEHEALTH SERVICES (in addition to Original Medicare)Primary care provider (PCP) 0 copayNot CoveredSpecialist 0 copayNot CoveredUrgent care services 0 copayNot CoveredSubstance abuse or behavioralhealth services 0 copayNot CoveredFITNESS AND WELLNESSSilverSneakers Fitness Program - Basic fitness center membershipincluding fitness classes.HOSPICEYou must get care from a Medicare-certified hospice. You must consult with your plan before you selecthospice.-Note: some services require prior authorization.2022-9-Summary of Benefits
Notes2022-10-Summary of Benefits
Important!At Humana, it is important you are treated fairly.Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, nationalorigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, marital status or religion.Discrimination is against the law. Humana and its subsidiaries comply with applicable Federal Civil Rightslaws. If you believe that you have been discriminated against by Humana or its subsidiaries, there are waysto get help. You may file a complaint, also known as a grievance:Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.If you need help filing a grievance, call 1-888-445-4788 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Officefor Civil Rights electronically through their Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human Services,200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html. California residents: You may also call California Department of Insurance toll-free hotline number:1-800-927-HELP (4357), to file a grievance.Auxiliary aids and services, free of charge, are available to you.1-888-445-4788 (TTY: 711)Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remoteinterpretation, and written information in other formats to people with disabilities when such auxiliary aidsand services are necessary to ensure an equal opportunity to participate.Language assistance services, free of charge, are available to you.1-888-445-4788 (TTY: 711)GCHJV5REN 0220
Find out moreYou can see your plan's provider directory at Humana.com or call us at thenumber listed at the beginning of this booklet and we will send you one.Humana is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in this Humana plandepends on contract renewal.If you want to compare our plan with other Medicare health plans, you can call your employer or unionsponsoring this plan to find out if you have other options through them.If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare& You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.Humana.comSB079409EN22
Humana Group Medicare Advantage PPO Plan PPO 079/409 Portico Benefit Services - Premium Plan . Humana.com: or call us at the number listed at the beginning of this booklet and we will send you one. Find out : . 2022 Summary of Benefits Keywords: Summary of Benefits, Prescription Drug Schedule Created Date:
