HumanaChoice PPO (h5216-043)
The HumanaChoice PPO is a Medicare Advantage (Medicare Part C) plan offered by Humana that uses a preferred provider organization (PPO). This network of preferred providers offers maximum coverage benefits. You can use doctors and other providers outside the network, but you will pay greater out-of-pocket costs.
- Written by Terry Turner
Terry Turner
Senior Financial Writer and Financial Wellness Facilitator
Terry Turner has more than 35 years of journalism experience, including covering benefits, spending and congressional action on federal programs such as Social Security and Medicare. He is a Certified Financial Wellness Facilitator through the National Wellness Institute and the Foundation for Financial Wellness and a member of the Association for Financial Counseling & Planning Education (AFCPE®).
Read More- Edited By
Lamia Chowdhury
Lamia Chowdhury
Financial Editor
Lamia Chowdhury is a financial content editor for RetireGuide and has over three years of marketing experience in the finance industry. She has written copy for both digital and print pieces ranging from blogs, radio scripts and search ads to billboards, brochures, mailers and more.
Read More- Published: September 9, 2022
- Updated: January 17, 2023
- 4 min read time
- This page features 4 Cited Research Articles
- Edited By
HumanaChoice PPO Medicare CMS Star Ratings
It is not available in all states or counties.
The HumanaChoice PPO received four of five stars over all in the CMS Star Rating system for 2022. One star represents poor performance while five stars represents excellent performance.
The U.S. Centers for Medicare & Medicaid Services issue Medicare Advantage ratings based on the experiences of people enrolled in Medicare Advantage and Medicare Part D prescription drug plans.
The overall rating is based on the individual ratings for the HumanaChoice PPO health and drug plans.
HumanaChoice PPO Health Plan Rating
The HumanaChoice PPO health plan received 4 1/2 out of five stars in the CMS Star Rating system,
It received five-star ratings in 10 of the 33 criteria Medicare uses to rate Medicare Advantage health plans.
- Assessment of members’ health care needs and risks
- Beneficiaries with diabetes whose blood sugar is under control
- Colorectal screenings
- Customer service
- Low number of complaints about the plan
- Timely decisions about appeals
- Fairness of appeals decisions (made by an independent reviewer)
- TTY and foreign language interpreters when calling the plan
- Yearly pain screening and pain management
- Yearly review of members’ drugs and supplements
The plan’s lowest rating was one for zero stars — for failing to provide information or help when a plan member requested it. It received two, two-star ratings — member rating of the plan and reducing the risk of falls.
But it also received 13 four-star ratings.
HumanaChoice PPO Drug Plan Rating
The HumanaChoice PPO prescription drug plan also received a 4 1/2 out of five stars from Medicare.
It received five-star ratings for five of the 16 criteria Medicare uses to rate Medicare Advantage drug plans.
- Changes to the plan’s performance resulting from customer complaints
- Customer service
- Improvement to plan’s performance
- Low number of complaints about the plan
- TTY and foreign language interpretation services when beneficiaries call the plan
The lowest ratings the drug plan received were three-star ratings in three categories.
- Accurate drug pricing information provided through the Medicare Plan Finder website
- Making sure beneficiaries with diabetes take the most effective drugs for high-cholesterol
- Members’ rating of the plan
Costs and Coverage
In addition to a premium for the HumanaChoice PPO, you still have to pay the Medicare Part B medical insurance premium — $170.10 in 2022.
| SERVICE | IN-NETWORK |
|---|---|
| Medical Premiums | $10 |
| Medical Deductible | N/A |
| Drug Plan Premium | $10 |
| Prescription Deductible | $250 |
| Maximum Out-of-Pocket (in-network) | $6,700 |
Health Care Services and Durable Medical Equipment (DME) Coverage
The HumanaChoice PPO offers the same coverage as Original Medicare, but also includes extra benefits that Original Medicare does not cover.
| BENEFIT | OUT-OF-POCKET COSTS IN-NETWORK | OUT-OF-POCKET COSTS OUT-OF-NETWORK |
|---|---|---|
| Ambulance services (ground only) | $290 | $290 |
| Diabetes supplies | $0 copay or 10% – 20% of the item’s cost | 25% of the item’s cost |
| Diagnostic tests and procedures | $0 – $175 copay | $0 – $60 copay or 40% coinsurance |
| Diagnostic Radiology services (MRI, CT scans) | $35 – $325 copay | $65 copay or 40% coinsurance |
| Lab services | $0 – $50 copay | 40% coinsurance |
| Outpatient X-rays | $0 – $95 copay | $25 – $65 copay or 40% coinsurance |
| Primary care visits | $0 copay | $25 copay |
| Specialist visits | $35 copay | $65 copay |
| Durable medical equipment | 20% coinsurance per item | 20% – 40% coinsurance per item |
| Prosthetics | 20% coinsurance per item | 25% coinsurance per item |
| Emergency care | $90 copay | $90 copay |
| Urgent Care | $0 – $65 copay or 40% coinsurance | $0 – $65 copay or 40% coinsurance |
| Inpatient hospital care | $31 per day for days 1 – 5 $0 per day for days 6 – 90 | $475 per day for days 1 – 25 $0 per day for days 26 – 90 |
Dental, Vision and Hearing Benefits
Like many Medicare Advantage plans, the HumanaChoice PPO offers hearing, vision and dental benefits as part of its coverage.
| BENEFIT | OUT-OF-POCKET COSTS IN-NETWORK | OUT-OF-POCKET COSTS OUT-OF-NETWORK |
|---|---|---|
| Dental services — oral exam | $0 copay | 50% – 75% coinsurance |
| Dental cleaning | 0% – 70% coinsurance | 50% – 75% coinsurance |
| Dental — fluoride treatments | $0 copay | 50% – 75% coinsurance |
| Dental X-rays | $0 copay | 50% – 75% coinsurance |
| Dental restorative services | 50% coinsurance | 55% – 75% coinsurance |
| Dental — periodontics | 70% coinsurance | 55% – 75% coinsurance |
| Dental extractions | 50% coinsurance | 55% – 75% coinsurance |
| Routine eye exam | $0 copay | $0 copay |
| Contact Lenses | $0 copay | $0 copay |
| Eyeglasses | $0 copay | $0 copay |
| Hearing exam | $35 copay | $65 copay |
| Hearing aids | $699 – $999 copay | $699 – $999 copay |
| Hearing aid fitting and evaluation | $0 copay | $0 copay |
Prescription Drug Costs and Coverage
The HumanaChoice PPO includes a Medicare Part D drug plan which has a five-tier formulary.
It’s important to check before buying any Part D coverage to make sure that drugs you take are part of the plans’ formulary.
| Tier | 1 Month Preferred Retail | 3 Month Preferred Retail | 1 Month Standard Retail | 3 Month Standard Retail | 1 Month Preferred Mail Order | 3 Month Preferred Mail Order | 1 Month Standard Mail Order | 3 Month Standard Mail Order |
|---|---|---|---|---|---|---|---|---|
| Tier 1 Preferred Generic | $3 | $9 | $10 | $30 | $3 | $9 | $10 | $30 |
| Tier 2 Generic | $10 | $30 | $20 | $20 | $10 | $0 | $20 | $60 |
| Tier 3 Preferred Brand Name | $47 | $141 | $47 | $141 | $47 | $131 | $47 | $141 |
| Tier 4 Non- Preferred Drug | $99 | $297 | $199 | $300 | $99 | $287 | $100 | $300 |
| Tier 5 Specialty Drugs | 28% | N/A | 28% | N/A | 28% | N/A | 28% | N/A |
Gap coverage kicks in once your total costs paid by the plan and you — out of your own pocket — total $4,430. After that — and up until you hit the MOOP threshold of $6,350 — you pay 25% for both generic and brand name drugs.
Once you hit the $6,350 limit, you pay $3.95 or 5% — whichever is greater — for each generic drug. And you pay $9.85 or 5% — whichever is greater — for each brand name drug.
- Association for Financial Counseling & Planning Education (AFCPE®) member
- Holds six Health Literacy certificates from the CDC
- Emmy® Award winner
4 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2022, April 29). CY 2023 Medicare Advantage and Part D Final Rule (CMS-4192-F). Retrieved from https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-final-rule-cms-4192-f
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Costs at a Glance. Retrieved from https://www.medicare.gov/basics/costs/medicare-costs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Your Medicare Costs. Retrieved from https://www.medicare.gov/basics/costs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). 2022 Medicare Costs. Retrieved from https://www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf
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