Transcription
PUB Name: GSB0112021Summary of BenefitsHumana Group Medicare Advantage HMO PlanHMO 076/609State of FloridaY0040 GHHKLRWEN21 MHMO 076/609
Our service area includes the following: Florida: Alachua, Baker, Bay, Broward, Charlotte,Citrus, Clay, Collier, Columbia, Duval, Escambia, Flagler, Glades, Hardee, Hernando, Highlands,Hillsborough, Lake, Lee, Manatee, Marion, Martin, Miami-Dade, Nassau, Okaloosa,Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Santa Rosa,Sarasota, Seminole, St. Johns, St. Lucie, Sumter, Volusia, Walton
Let's talk about the Humana GroupMedicare Advantage HMO Plan.Find out more about the Humana Group Medicare Advantage HMO 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 HMO plan, you must beentitled to Medicare Part A, beenrolled in Medicare Part B, and live inour service area.Humana Group Medicare Advantage HMO planhas a network of doctors, hospitals, and otherproviders. For more information, please callGroup Medicare Customer Care.Plan name:Humana Group Medicare AdvantageHMO planHow to reach us:A healthy partnershipMembers should call toll-free1-800-555-7997 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.com2021-3-Summary of Benefits
Monthly Premium, Deductible and Limits-IN-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 Maximum Out-of-Pocket 1,000 out-of-pocket limit for Medicare-covered services. Thefollowing services do not apply to the maximum out-of-pocket: Part DPharmacy, COVID-19 Care Package ; COVID-19 Testing ; COVID-19Treatment ; Fitness Program ; Health Education Services ; HearingServices (Routine) ; Meal Benefit ; OTC Drugs and Supplies ; PodiatryServices (Routine) ; Smoking Cessation (Additional) ; Transportation(Routine) ; Vision Services (Routine) and the Plan Premium.If you reach the limit on out-of-pocket costs, we will pay the full costfor the rest of the year on covered hospital and medical services.Covered Medical and Hospital Benefits-IN-NETWORKACUTE 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. 100 per admitOUTPATIENT HOSPITAL COVERAGEOutpatient hospital visits 0 to 10 copayAmbulatory surgical center 0 copayDOCTOR OFFICE VISITSPrimary care provider (PCP) 0 copaySpecialists 10 copayNote: some services require prior authorization and referrals from providers.2021-4-Summary of BenefitsNote: This information applies to Alabama, Arkansas, Colorado, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Mississippi, Montana, Nebraska, New Hampshire, New Mexico, New York, Ohio, Oklahoma, Pennsylvania, SouthCarolina, South Dakota, Tennessee, Virginia, and Wisconsin residents only – Your primary care physician (PCP) determines what specialists to refer patients to or you may self refer to any network specialist for certain covered services. Noreferral is necessary in the case of emergency, urgently needed care, or out-of-area kidney dialysis. Please see your Evidence of Coverage for a complete list of services requiring prior authorization.
Covered Medical and Hospital Benefits-IN-NETWORKPREVENTIVE CAREIncluding: Annual Wellness Visit,flu vaccine, colorectal cancer andbreast cancer screenings. Anyadditional preventive servicesapproved by Medicare during thecontract year will be covered.Covered at no cost.EMERGENCY CAREEmergency roomIf you are admitted to thehospital within 24 hours for thesame condition, you do not haveto pay your share of the cost foremergency care. See the"Inpatient Hospital Care" sectionof this booklet for other costs. 65 copay for Medicare-covered emergency room visit(s)Urgently needed servicesUrgently needed services are careprovided to treat anon-emergency, unforeseenmedical illness, injury or conditionthat requires immediate medicalattention. 0 to 10 copayDIAGNOSTIC SERVICES, LABS AND IMAGINGDiagnostic radiology 0 to 10 copayLab services 0 copayDiagnostic tests and procedures 0 to 10 copayOutpatient X-rays 0 to 10 copayRadiation therapy 10 copayHEARING SERVICESMedicare-covered hearing 10 copayRoutine hearingRoutine hearing exam (1 per year) - 0HearUSA provider must be used.Contact Customer Service tolocate a provider.Hearing aid fitting/evaluation (1 per year) - 0Hearing aid(s) (all types) (1 per ear per year) - 500 per ear per yearNote: Includes 1 month battery supply and 2 year warrantyDENTAL SERVICESMedicare-covered dental 10 copayNote: some services require prior authorization and referrals from providers.2021-5-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKVISION SERVICESMedicare-covered visionservices 10 copayMedicare-covered diabetic eyeexam 0 copayMedicare-covered glaucomascreening 0 copayMedicare-covered eyewear(post-cataract) 0 copayRoutine vision 0 copay for routine exam up to 1 per year.MENTAL HEALTH SERVICESInpatientThe 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 100 per admitOutpatient group and individualtherapy visits 0 to 10 copaySKILLED NURSING FACILITYOur plan covers up to 100 days ina SNF. 0 copay per day for days 1-100No 3-day hospital stay isrequired.Plan pays 0 after 100 daysPHYSICAL THERAPY 5 to 10 copayNote: some services require prior authorization and referrals from providers.2021-6-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKAMBULANCEPer date of service regardless ofthe number of trips.Limited to Medicare-coveredtransportation.- 0 copayTRANSPORTATIONLogistiCare provider must beused. Contact Customer Serviceto locate a provider. 0 copay for plan approved location up to 50 one-way trip(s) peryear by car, van, wheelchair access vehicle.PART B PRESCRIPTION DRUGS-0% to 20% of the costACUPUNCTURE SERVICESMedicare-covered acupuncture 10 copayLimit 20 visit(s) per yearALLERGYAllergy shots & serum 0 copayCHIROPRACTIC SERVICESMedicare-covered chiropracticvisit(s) 10 copayCOVID-19Testing and Treatment 0 copay for testing and treatment services for COVID–19Health Essentials KitKit includes over the counter items useful for preventing the spread ofCOVID–19 and other viruses. Limited one per year.DIABETES MANAGEMENT TRAINING- 0 copayFOOT CARE (PODIATRY)Medicare-covered foot care 10 copayRoutine foot care 10 copayHOME HEALTH CARE- 0 copayMEDICAL EQUIPMENT/SUPPLIESDurable medical equipment(like wheelchairs or oxygen)0% of the costMedical supplies0% of the costNote: some services require prior authorization and referrals from providers.2021-7-Summary of Benefits
Covered Medical and Hospital Benefits-IN-NETWORKProsthetics (artificial limbs orbraces)0% of the costDiabetes monitoring supplies 10 copayOUTPATIENT SUBSTANCE ABUSEOutpatient group and individualsubstance abuse treatmentvisits 0 to 10 copayOVER-THE-COUNTER ITEMS- 50 maximum benefit coverage amount per quarter (3 months) forselect over-the-counter health and wellness products.REHABILITATION SERVICESOccupational and speechtherapy 5 to 10 copayCardiac rehabilitation 5 to 10 copayPulmonary rehabilitation 5 to 10 copayRENAL DIALYSISRenal dialysis 0 copayKidney disease educationservices 0 copayTELEHEALTH SERVICES (in addition to Original Medicare)Primary care provider (PCP) 0 copaySpecialist 10 copayUrgent care services 0 copaySubstance abuse or behavioralhealth services 0 copayFITNESS 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 and referrals from providers.2021-8-Summary of Benefits
Notes2021-9-Summary of Benefits
Notes2021-10-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 1-800-555-7997 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.1-800-555-7997 (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.1-800-555-7997 (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 HMO 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.comHMO 076/609
Humana Group Medicare Advantage HMO Plan HMO 076/609 State of Florida. Our service area includes the following: Florida: . Humana.com. or call us at the number listed at the beginning of this booklet and we will send you one. Find out . . 2021 Summary of Benefits Keywords: Summary of Benefits, Prescription Drug Schedule Created Date:
