| 2020 Medicare Advantage Plan Details | |||||
|---|---|---|---|---|---|
| Medicare Plan Name: | Humana Gold Plus SNP-DE H5619-093 (HMO D-SNP) | ||||
| Location: | Baldwin, Alabama | ||||
| Plan ID: | H5619 – 093 – 0 | ||||
| Member Services: | 1-800-457-4708 TTY users 711 | ||||
| — Enrollment Options — | |||||
| Medicare Contact Information: | 1-800-MEDICARE (1-800-633-4227) TTY users 1-877-486-2048 |
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 Medicare plan advice at no cost from licensed insurance agents. Call: 888-205-9813 / TTY 711
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| — Medicare Plan Features — | |||||
| Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) | ||||
| Annual Deductible: | $0 for people who qualify for both Medicare and Medicaid. | ||||
| Annual Initial Coverage Limit (ICL): | $4,020 | ||||
| Health Plan Type: | Local HMO | ||||
| Special Needs Plan (SNP) Eligibility Requirement: |
Dual-Eligible | ||||
| Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
| Total Number of Formulary Drugs: | 3,379 drugs | ||||
| This plan has 5 drug tiers. | |||||
| Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
| • Preferred Pharmacy Cost-Sharing during initial coverage phase: |
$0.00 | $6.00 | $47.00 | $100.00 | 25% |
| • Number of Drugs per Tier: |
300 | 597 | 768 | 1104 | 610 |
| Plan’s Pharmacy Search: | |||||
| Plan Offers Mail Order? | Yes | ||||
| Number of Members enrolled in this plan in Baldwin, Alabama: | 565 members | ||||
| Number of Members enrolled in this plan in Alabama: | 9,229 members | ||||
| Number of Members enrolled in this plan in (H5619 – 093): | 9,413 members | ||||
| Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
| • Customer Service Rating: | 5 out of 5 Stars. | ||||
| • Member Experience Rating: | 4 out of 5 Stars. | ||||
| • Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
| — Plan Premium Details — | |||||
| The Monthly Premium is Split as Follows: | Total Premium |
Part C Premium |
Part D Base Premium |
Part D Supplemental Premium |
|
| $19.50 | $0.00 | $19.50 | $0.00 | ||
| Monthly Premium with Extra Help Low-Income Subsidy (LIS): | 100% Subsidy |
75% Subsidy |
50% Subsidy |
25% Subsidy |
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| Monthly Part D Premium with LIS: | $0.00 | $4.90 | $9.70 | $14.60 | |
| Total Monthly Premium with LIS (Parts C & D): | $0.00 | $4.90 | $9.70 | $14.60 | |
| — Plan Health Benefits — | |||||
| ** Base Plan ** | |||||
| Premium | Total monthly premium: $19.50 | ||||
| Health plan premium: $0.00 | |||||
| Drug plan premium: $19.50 | |||||
| Standard Part B premium: $135.50 | |||||
| Part B premium reduction: No | |||||
| Deductible | Health plan deductible: Coming soon | ||||
| Drug plan deductible: $400.00 | |||||
| Estimated yearly costs | Estimated total yearly costs for care: $0.00 | ||||
| Out-of-pocket max | Out-of-pocket max: $6,700 In-network | ||||
| Doctor services | Primary doctor visit: 0% or 20% per visit | ||||
| Specialist visit: 0% or 20% per visit | |||||
| Tests, labs, & imaging | Diagnostic tests & procedures: $0 or 20%, Limits apply | ||||
| Lab services: $0 or 20%, Limits apply | |||||
| Diagnostic radiology services (like MRI): 0% or 20%, Limits apply | |||||
| Outpatient x-rays: 0% or 20%, Limits apply | |||||
| Emergency care: $0 or $90 per visit (always covered) | |||||
| Urgent care: 0% or 20% per visit (always covered) | |||||
| Hospital services | Inpatient hospital coverage: $0 or $1,969 per stay, Limits apply | ||||
| Outpatient hospital coverage: 0% or 20% per visit, Limits apply | |||||
| Skilled nursing facility | Skilled nursing facility: $0 per day for days 1 through 20 $0 or $178 per day for days 21 through 100, Limits apply | ||||
| Preventive services | Preventive services: $0 copay | ||||
| Ambulance | Ground ambulance: 0% or 20% | ||||
| Therapy services | Occupational therapy visit: 0% or 20%, Limits apply | ||||
| Physical therapy & speech & language therapy visit: 0% or 20%, Limits apply | |||||
| Mental health services | Outpatient group therapy with a psychiatrist: 0% or 20%, Limits apply | ||||
| Outpatient individual therapy with a psychiatrist: 0% or 20%, Limits apply | |||||
| Outpatient group therapy visit: 0% or 20%, Limits apply | |||||
| Outpatient individual therapy visit: 0% or 20%, Limits apply | |||||
| Opioid treatment services | Opioid treatment services: Covered | ||||
| Other services | Durable medical equipment (like wheelchairs & oxygen): 0% or 20% per item, Limits apply | ||||
| Prosthetics (like braces, artificial limbs): 0% or 20% per item, Limits apply | |||||
| Diabetes supplies: $0 or 20% per item, Limits apply | |||||
| Hearing | Hearing exam: 0% or 20%, Limits apply | ||||
| Fitting/evaluation: $0, Limits apply | |||||
| Hearing aids – All types: $0 copay, Limits apply | |||||
| Preventive dental | Oral exam: $0 copay, Limits apply | ||||
| Cleaning: $0 copay, Limits apply | |||||
| Fluoride treatment: $0 copay, Limits apply | |||||
| Dental x-rays: $0 copay, Limits apply | |||||
| Comprehensive dental | Non-routine services: $0, Limits apply | ||||
| Diagnostic services: Not covered | |||||
| Restorative services: $0, Limits apply | |||||
| Endodontics: $0, Limits apply | |||||
| Periodontics: $0, Limits apply | |||||
| Extractions: $0, Limits apply | |||||
| Prosthodontics, other oral/maxillofacial surgery, other services: $0, Limits apply | |||||
| Vision | Routine eye exam: $0, Limits apply | ||||
| Contact lenses: $0 copay, Limits apply | |||||
| Eyeglasses (frames & lenses): $0 copay, Limits apply | |||||
| Eyeglass frames (only): Not covered | |||||
| Eyeglass lenses (only): Not covered | |||||
| Upgrades: Not covered | |||||
| More benefits | Fitness benefit: Limited coverage | ||||
| Transportation services for non-emergency care: Any health-related locations: Not covered | |||||
| Transportation services for non-emergency care: Plan-approved locations: Limited coverage | |||||
| Over the counter drug benefits: Limited coverage | |||||
| In-home support services: Not covered | |||||
| Home and bathroom safety devices: Not covered | |||||
| Meals for short duration: Limited coverage | |||||
| Annual physical exams: Limited coverage | |||||
| Telehealth: Limited coverage | |||||
| Part B drugs | Chemotherapy drugs: 0% or 20%, Limits apply | ||||
| Other Part B drugs: $0 or 20%, Limits apply | |||||
