HumanaChoice H5216 318 PPO

If you’re diving into the details of Humana Medicare Advantage plan in 2025, you might stumble upon the ‘Humanachoice H5216 318 PPO’. This plan, offered by Humana, aims to combine the flexibility of provider choice with tailored healthcare coverage.

Often, the most pressing questions involve cost, coverage, and provider options. What are the plan’s premiums and deductibles?

Are prescriptions and specialized care services covered, and what’s the process for out-of-network care? Our comprehensive guide is designed to unravel the intricate details of coverage options, out-of-pocket costs, and additional benefits to help you determine whether this plan aligns with your healthcare needs.


Key Takeaways

  • The HumanaChoice H5216 318 PPO plan emphasizes preventive healthcare with $0 copayments for various in-network services, including home health services and diagnostics, with a focus on disease management and wellness education.


  • Members benefit from broad coverage including mental health, and specialized care like podiatry, and inpatient and skilled nursing services, with cost-sharing structures like copayments and coinsurance applicable, especially for out-of-network services.


  • Prescription drugs are tiered with varying copays; additional benefits include OTC items, vision, dental, and hearing aid coverage, as well as worldwide emergency care, with plan details and costs varying by location.

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Exploring the HumanaChoice H5216 318 PPO Plan


HumanaChoice H5216 318 PPO Exploring the HumanaChoice H5216 318 PPO Plan


Humana, a reputable organization, provides the HumanaChoice H5216 318 PPO as a part of their Medicare Advantage offerings, which include a variety of plan types like HMO, PPO, and PFFS. Enrollment in this plan is subject to the plan’s contract renewal.

It offers an extensive array of in-network benefits, ranging from home health services with a $0 copayment, to diagnostic procedures and tests that require a copayment between $0 and $65.

This plan is unique in its approach to healthcare. It’s not just about treating illnesses; it’s about preventing them.

For instance, it offers:

  • A $0 copayment for Medicare-covered supplies and services related to diabetes


  • A $10 copayment for therapeutic shoes or inserts


  • Coverage for chiropractic services, with a $20 copayment under Medicare coverage within the network.



Understanding Your Coverage Options

A variety of services are comprehensively covered in-network by the HumanaChoice H5216 318 PPO plan. Whether it’s home health care, skilled nursing facility services, or diagnostic tests, this plan’s got you covered.

But what truly sets it apart is its focus on preventive services and wellness education programs.

Screenings for health conditions like cardiovascular disease, diabetes, and cancer are all part of the package, as are counseling and therapy services.

These services are covered by Medicare and come with no copay, so you can focus on maintaining your health without worrying about cost. It’s a testament to the plan’s commitment to proactive health management.


Navigating Out-of-Network Benefits

Like all plans, the HumanaChoice H5216 318 PPO also has its own set of rules and limitations. When using out-of-network services, such as home health services or skilled nursing facility services, a coinsurance rate of 50% applies.

This means that while you enjoy the freedom of choosing your provider, you also bear a greater portion of the cost.

It’s also important to note that out-of-network providers are under no obligation to offer services to HumanaChoice H5216 318 PPO members, except in emergencies.

Therefore, to avoid unexpected expenses, it’s always a good idea to reference your Evidence of Coverage document to understand the specifics of cost-sharing for out-of-network services.


Health Services Under the Humana Plan


HumanaChoice H5216 318 PPO Health Services Under the Humana Plan


The HumanaChoice H5216 318 PPO plan aims to provide necessary services when needed, not only offering broad coverage. You can rest assured knowing that skilled nursing facility services are covered under this plan, providing you with the specialized care you need when required.

The cost-sharing structure for these services includes a daily copay. For the first 20 days, the copay is $20 per day, and for days 21 to 100, it increases to $203 per day.

However, it’s important to note that prior authorization is necessary before services are rendered.


Mental Health and Wellness

Equally prioritizing physical and mental health, the Humana plan provides extensive coverage. To this end, it offers extensive coverage for mental health services.

Outpatient mental health services in-network have a copayment of $30 for individual and group Medicare-covered sessions.

For those who require inpatient care, the plan provides coverage with a copayment of $295 per day for the first 5 days. From day 6 to day 90, no copayment is required.

Prior authorization is required for both in-network outpatient care and substance abuse services, ensuring that members receive the specialized attention they need.


Specialized Care Services

Alongside a wide range of general health services, the Humana plan also offers specialized care services. One such service is podiatry, which is part of the plan benefits. For Medicare-covered podiatry services within the network, the plan requires a copay of $30 and prior authorization.

Another important specialized care service covered under the plan is durable medical equipment. These items, which are essential for many patients, are subject to a 20% coinsurance and require prior authorization.

This coverage can be a significant relief for those who rely on such equipment for their daily living.

Cost Structure of the HumanaChoice H5216 318 PPO

Like any healthcare plan, cost is a pivotal consideration for the HumanaChoice H5216 318 PPO plan. The costs, coverage, and benefits of the plan may differ based on where the enrollee is located.

This means that the plan’s offerings could be customized to better suit the individual’s needs. One constant, however, is that members of the plan need to pay their Medicare Part B premium in addition to the plan’s monthly premium.


Premiums and Deductibles

Affordability is a hallmark of the HumanaChoice H5216 318 PPO plan design. The monthly premium for the plan is $0.00.

This means that you can enjoy the extensive coverage and benefits that the plan offers without having to worry about a monthly premium.

Moreover, the plan features an annual deductible of $0. This means there’s no set amount you need to spend on healthcare services during the year before your plan starts to pay its share.

This feature further enhances the affordability of the plan.

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Understanding Cost-Sharing

To maximize the benefits of your healthcare plan, it’s important to understand cost-sharing. In-network lab services under the HumanaChoice H5216 318 PPO typically require a copay of $0 to $25, depending on the type of service and whether prior authorization is necessary.

For out-of-network lab services, the plan enforces a 50% coinsurance, and services may also require prior authorization.

Furthermore, the plan includes a Maximum Out-of-Pocket Limit for Parts A & B services set at $3,700. This serves as a cap on your total cost-sharing responsibilities within a year, ensuring that your healthcare costs remain manageable.


Prescription Drug Benefits


HumanaChoice H5216 318 PPO Prescription Drug Benefits


The HumanaChoice H5216 318 PPO plan includes the following features:

  • Mail-order pharmacy option for convenience and potential savings


  • Tiered system for prescription drug cost-sharing


  • Copays range from $0.00 for Tier 1 up to 33% for Tier 5 during the initial coverage phase.


The plan’s pharmacy network includes limited lower-cost, preferred pharmacies in various urban, suburban, and rural areas. This indicates extensive coverage and access to affordable medication for members regardless of their location.

To maximize savings on prescription medications, members can use the online pharmacy directory or contact Customer Care to locate lower-cost preferred pharmacies in their area.


Convenience of Mail Order

Medications delivered right to your doorstep become a reality with the HumanaChoice H5216 318 PPO plan. Members can access their medications through a convenient mail-order service, saving them the hassle of visiting a pharmacy in person.

It’s just another way the plan helps make healthcare more accessible and convenient for its members.


Coverage Details for Medications

The HumanaChoice H5216 318 PPO plan offers coverage for a wide range of prescription drugs, including insulin, as well as diabetes supplies and services, such as therapeutic shoes or inserts.

For those managing diabetes, this could mean significant savings. Insulin on the Medicare Part D plan’s formulary will have a monthly copay of $35 or less.

The plan also covers diabetic supplies, including tools for diabetes care such as blood glucose monitors and test strips. These items come with specific copayments and coinsurance rates and are limited to specified manufacturers as per the plan’s Evidence of Coverage.

Additionally, members can benefit from a $50 maximum benefit every three months for over-the-counter (OTC) items, including nicotine replacement therapy as a Part C OTC benefit.

Additional Plan Features


HumanaChoice H5216 318 PPO Additional Plan Features


Beyond basic healthcare coverage, the HumanaChoice H5216 318 PPO plan offers more benefits.

It includes an Over-the-counter (OTC) Items benefit, which provides members with a maximum plan benefit of $50 every three months for OTC items, including nicotine replacement therapy.

This is a unique feature that not only adds value to the plan but also promotes proactive health management.


Vision and Dental Care

Acknowledging the importance of vision and various dental plans in overall health, the Humana plan extends its coverage to these areas.

The plan provides a routine eye exam once per year, with in-network vision services offering a maximum plan benefit of $75 for combined in and out-of-network services.

On the dental front, the plan offers a $0 copayment for procedures such as:

  • oral evaluations


  • scaling


  • root planing


  • fluoride treatment


  • restorative services like crowns and root canals


These benefits are subject to an annual maximum benefit.

For eyewear, the plan covers one pair of eyeglasses (lenses and frames) or contact lenses per year with a $0 copayment and provides a $250 maximum benefit annually for all non-Medicare-covered eyewear.

The comprehensive dental services come with a combined maximum benefit of $4,000 per year.


Hearing Aid Coverage

Recognizing hearing as a vital aspect of life, the HumanaChoice H5216 318 PPO plan provides coverage for hearing aids. It provides coverage for hearing aids, featuring:

  • Lower copayments for basic models to promote affordability


  • Within the network, the plan offers a $30 copayment for Medicare-covered hearing exams


  • Hearing aids come with a copayment ranging from $99 to $399


  • Accommodating up to two aid purchases per year


Even when you venture out-of-network, the plan maintains the same copayment structure for routine exams and fitting/evaluation for hearing aids as those provided in-network. This consistency in coverage ensures that you can access the hearing services you need, regardless of your location.


Emergency and Urgent Care Provisions


HumanaChoice H5216 318 PPO Emergency and Urgent Care Provisions


Given that emergencies can happen at any time, it’s essential to have a plan that’s prepared for such situations. The HumanaChoice H5216 318 PPO plan provides coverage for emergency and urgent care, ensuring that you’re not left in a lurch when you need care the most.

Whether it’s a sudden illness or an unexpected injury, you can have peace of mind knowing that your plan has got you covered.

Whether you’re at home or traveling, the worldwide emergency coverage of the plan ensures that you can access the emergency care you need, no matter where you are.

The plan also covers urgent care, so you can get prompt treatment for non-life-threatening conditions that require immediate attention. Remember, in an emergency, it’s crucial to seek care immediately and notify your plan as soon as possible.

Plan Accessibility Across Locations

Provided by Humana, a Medicare Advantage organization, the HumanaChoice H5216 318 PPO is one among various plan types like HMO, PPO, and PFFS. The availability of this plan is contingent upon the enrollee’s state and local market.

This means that the benefits and coverage you enjoy may vary depending on where you live. Therefore, it’s always a good idea to check with Humana directly to understand the specifics of the plan in your location.


Maximizing Your Plan Benefits

Utilizing the provided resources and actively participating in health and wellness programs is key to maximizing the benefits of your HumanaChoice H5216 318 PPO plan.

Reviewing the Evidence of Coverage document is crucial in understanding the full range of benefits and services available, ensuring you can make informed decisions about your healthcare.

Members can access the Evidence of Coverage online or request a paper copy, which provides detailed information about the plan’s benefits, coverage rules, and costs. Members also have access to a variety of member services designed to help them navigate their health coverage and maximize their plan benefits.

To take full advantage of the plan, members should actively use the provided resources such as a nurse advice hotline, online chat, or customer service for personalized assistance with their healthcare needs.

Lastly, don’t forget to use the mail-order pharmacy benefits to save on prescription medications.



Navigating the world of healthcare can be challenging, but with the right plan and knowledge, it doesn’t have to be.

The HumanaChoice H5216 318 PPO is a Medicare Advantage plan that offers comprehensive coverage, a wide range of services, and added features like a $0 monthly premium, mail-order pharmacy services, and worldwide emergency coverage.

With its focus on preventive care, wellness programs, and specialized services, this plan is designed to support your health at every stage.

So go ahead, make the most of your healthcare plan, and live your best life!

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Frequently Asked Questions


What does Humana PPO mean?

Humana PPO, or HumanaChoice PPO, refers to preferred provider organization plans that offer the same basic benefits as Original Medicare and may include additional benefits. PPO plans provide a network of healthcare providers at agreed-upon rates, similar to an HMO plan.


What insurance is H5216?

H5216 refers to the Medicare Advantage PPO plan – Humana Choice H5216-001 (PPO), which is a Medicare Advantage PPO plan with a Medicare contract. Keep in mind that the coverage details provided are a summary and may not include every service or limitation.


What mental health services does the Humana plan cover?

The Humana plan provides comprehensive coverage for mental health services, including outpatient sessions with a copayment of $30 for individual and group Medicare-covered sessions. This information should give you a clear understanding of the mental health services covered by the Humana plan.


Does the plan cover prescription drugs?

Yes, the HumanaChoice H5216 318 PPO plan covers a wide range of prescription drugs, including insulin and diabetes supplies and services.


What vision and dental care benefits does the plan provide?

The plan provides a routine eye exam once per year with a maximum benefit of $75 for in-network vision services, and dental services include a $0 copayment for certain procedures.

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