Summary of Benefits Humana Medicare Employer PPO Plan - 2014 PPO 079/084
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2014
Summary of Benefits
Humana Medicare
Employer PPO Plan
PPO 079/084
Y0040_GHHHPHPEN14 (Pending CMS Approval) PPO 079/084Thank you for your interest in the Humana Medicare Employer PPO Plan. Our plan is offered by Humana Health Insurance Company of Florida, Inc., Humana Insurance of Puerto Rico, Inc., Humana Insurance Company of New York, and Humana Insurance Company; all are Medicare Advantage PPO organizations that contract with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call the Humana Medicare Employer PPO Plan and ask for the “Evidence of Coverage”. YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (Fee-for-Service) Medicare Plan. Another option is a Medicare health plan, like the Humana Medicare Employer PPO Plan. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may be able to join or leave a plan only at certain times. Please call the Humana Medicare Employer PPO Plan at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. HOW CAN I COMPARE MY OPTIONS? You can compare the Humana Medicare Employer PPO Plan and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. WHERE IS THE HUMANA MEDICARE EMPLOYER PPO PLAN AVAILABLE? The service area for this plan includes: Alabama: Autauga, Barbour, Bibb, Blount, Bullock, Chambers, Chilton, Coffee, Colbert, Dale, Elmore, Fayette, Henry, Houston, Jackson, Jefferson, Lauderdale, Lee, Limestone, Lowndes, Macon, Madison, Marion, Marshall, Montgomery, Morgan, Randolph, Russell, Shelby, St. Clair, Walker, Wilcox; Arkansas: Crittenden; Arizona: La Paz, Mohave, Pima, Pinal, Santa Cruz, Yavapai; Florida: Martin, St. Lucie; Georgia: Bryan, Bulloch, Burke, Camden, Chatham, Chattahoochee, Clarke, Columbia, Effingham, Elbert, Evans, Franklin, Glascock, Glynn, Greene, Habersham, Hancock, Harris, Hart, Jackson, Jefferson, Liberty, Lumpkin, Madison, Marion, McDuffie, McIntosh, Morgan, Muscogee, Oconee, Oglethorpe, Rabun, Randolph, Richmond, Screven, Stephens, Stewart, Talbot, Taliaferro, Towns, Troup, Union, Warren, Washington, Webster, Wilkes; Idaho: Bannock, Booneville, Kootenai; Indiana: Adams, Allen, Cass, De Kalb, Elkhart, Fulton, Grant, Huntington, Kosciusko, La Porte, Lagrange, Marshall, Miami, Noble, St. Joseph, Steuben, Wabash, Wells, Whitley; Louisiana: Calcasieu, Caldwell, Cameron, La Salle, Lafayette, Morehouse, Ouachita, St. Laundry, St. Martin, St. Mary, Washington; Mississippi: Benton, DeSoto, George, Grenada, Hancock, Harrison, Jackson, Lafayette, Marshall, Pearl River, Stone, Tate, Tunica, Yalobusha; North Carolina: Alamance, Alexander, Alleghany, Anson, Cabarrus, Caldwell, Caswell, Catawba, Chatham, Cleveland, Davidson, Davie, Durham, Forsyth, Franklin, Gaston, Guilford, Iredell, Lee, Lincoln, Mecklenburg, Montgomery, Moore, Orange, Person, Randolph, Rockingham, Rowan, Stanly, Stokes, Union, Vance, Wake, Warren, Wilkes, Yadkin; New Mexico: Bernalillo, Catron, Cibola, Colfax, Curry, DeBaca, Dona Ana, Grant, Guadalupe, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Sierra, Socorro, Taos, Torrance, Union, Valencia; South Carolina: Aiken, Barnwell, Newberry, Saluda; Tennessee: Anderson, Bedford, Blount, Campbell, Cheatham, Claiborne, Cocke, Cumberland, Davidson, DeKalb, Dickson, Fayette, Fentress, Grainger, Hamblen, Hardin, Hickman, Jackson, Jefferson, Knox, Lewis, Loudon, Macon, Madison, Marshall, Maury, Monroe, Montgomery, Morgan, Overton, Roane, Robertson, Rutherford, Scott, Sevier, Shelby, Smith, Sumner, Trousdale, Union, Wayne, White, Williamson; Texas: El Paso; Utah: Beaver, Daggett, Davis, Emery, Piute, Salt Lake, Tooele, Uintah, Utah, Weber; Virginia: Albemarle, Bristol City, Buchanan, Buckingham, Charlottesville City, Dickenson, Fluvanna, Grayson, Greene, Lee, Nelson, Norton City, Russell, Scott, Smyth, Tazewell, Washington, Wise, Wythe; Washington: Island, King, Kitsap, Pierce, Snohomish, Spokane, Whatcom; West Virginia: Boone, Braxton, Cabell, Clay, Fayette, Kanawha, Lewis, Lincoln, Mercer, Monroe, Nicholas, Putnam, Roane, Upshur, Wayne, Webster. The employer, union or trust determines where they are going to offer the plan. Page 2 of 16
WHO IS ELIGIBLE TO JOIN THE HUMANA MEDICARE EMPLOYER PPO PLAN?
You can join the Humana Medicare Employer PPO Plan if you are entitled to Medicare Part A and enrolled in Medicare
Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll
in the Humana Medicare Employer PPO Plan unless they are members of our organization and have been since their
dialysis began.
CAN I CHOOSE MY DOCTORS?
The Humana Medicare Employer PPO Plan has formed a network of doctors, specialists, and hospitals. You can use
any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in
our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at
http://www.humana.com/members/tools. Our Group Medicare Customer Care number is listed at the end of
this introduction.
WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK?
You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for the services you
receive outside the network, and you may have to follow special rules prior to getting services in and/or out of network.
For more information, please call the Group Medicare Customer Care number at the end of this introduction.
DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?
The Humana Medicare Employer PPO Plan does cover Medicare Part B prescription drugs. The Humana Medicare
Employer PPO Plan does NOT cover Medicare Part D prescription drugs.
WHAT ARE MY PROTECTIONS IN THIS PLAN?
All Medicare Advantage Plans agree to stay in the program for a full year at a time. Plan benefits and cost-sharing may
change from year to year. Each year, plans can decide whether to continue to participate with Medicare Advantage.
Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not
to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end.
The letter will explain your options for Medicare coverage in your area.
As a member of the Humana Medicare Employer PPO Plan, you have the right to request an organization
determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to
file a grievance. You have the right to request an organization determination if you want us to provide or pay for an
item or service that you believe should be covered. If we deny coverage for your requested item or service, you have
the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination
or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to
regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision.
Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network
providers that does not involve coverage for an item or service. If your problem involves quality of care, you also
have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the
Evidence of Coverage (EOC) for the QIO contact information.
WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to,
the following types of drugs. Contact the Humana Medicare Employer PPO Plan for more details.
• S ome Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be
the patient) under doctor supervision.
• Osteoporosis Drugs: Injectable osteoporosis drugs for some women.
• Erythropoietin: By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or
transplantation) and need this drug to treat anemia.
Page 3 of 16• H emophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
• Injectable Drugs: Most injectable drugs administered incident to a physician’s service.
• Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in
a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary
payer for Medicare Part A coverage.
• Some Oral Cancer Drugs: If the same drug is available in injectable form.
• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
• Inhalation and Infusion Drugs administered through Durable Medical Equipment.
WHERE CAN I FIND ADDITIONAL INFORMATION?
Our Group Medicare Customer Care number is listed below.
Please call Humana for more information.
Visit us at www.humana.com or, call us at 1-866-396-8810 (TTY:711)
Group Medicare Customer Care hours are Monday - Friday from 8 a.m. - 9 p.m. Eastern time
This document may be available in other formats such as Braille, large print or other alternate formats.
This document may be available in a non-English language. For additional information, call Group Medicare Customer
Care at the phone number listed on the next pages.
Page 4 of 16Page 5 of 16
Page 6 of 16
Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Out-of- None 100% after $6,700 for 100% after $7,500
Pocket In-Network services per for In and Out-of-
Maximum plan year (If you reach Network services per
this maximum, no plan year (If you reach
further out-of-pocket this maximum, no
will be required of you further out-of-pocket
for covered expenses will be required of you
during the year. for covered expenses
Expenses for outpatient during the year.
Part D prescription Expenses for outpatient
drugs, over-the-counter Part D prescription
drugs and supplies, drugs, over-the-counter
and plan premiums do drugs and supplies, care
not apply toward this during foreign travel
maximum) and plan premiums do
not apply toward this
maximum)
Physician Office visits in 80% after $147 100% per visit after 60% after $300
Services conjunction with an deductible $15 copayment to combined annual
illness or injury primary care physician; deductible
or 100% per visit after
$35 copayment to
specialists
Allergy injections 80% after $147 100% 100% after $300
and serum deductible combined annual
deductible
Diagnostic tests 80% after $147 100% per visit after 60% after $300
and X-rays deductible $15 copayment to combined annual
primary care physician; deductible
or 100% per visit after
$35 copayment to
specialists
Medicare-approved 100% 100% per visit after 60% after $300
lab services $15 copayment to combined annual
primary care physician; deductible
or 100% per visit after
$35 copayment to
specialists
Page 7 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Preventive –A
bdominal Aortic 100% for all preventive 100% for all preventive 60% after $300
Services Aneurysm Screening services covered under services covered under combined annual
–B one Mass Original Medicare. Original Medicare at deductible
Measurement. zero cost sharing.
Covered once every Any additional Immunizations
24 months (more preventive services Any additional covered at 100%
often if medically approved by Medicare preventive services
necessary) if you mid-year will be approved by Medicare Smoking and Tobacco
meet certain medical covered by Original mid-year will be Use Cessation covered
conditions. Medicare. covered by the plan or at 50% after $300
by Original Medicare. combined annual
–C ardiovascular deductible
Screening Plan covers a physical
– Cervical and Vaginal exam annually.
Cancer Screening.
Covered once every 2
years. Covered once a
year for women with
Medicare at high risk.
–C
olorectal Cancer
Screening
–D
iabetes Screening
– I nfluenza Vaccine
–H
epatitis B Vaccine
for people with
Medicare who are at
risk
–H
IV Screening. $0
copay for the HIV
screening, but you
generally pay 20%
of the Medicare-
approved amount
for the doctor’s visit.
HIV screening is
covered for people
with Medicare who
are pregnant and
people at increased
risk for the infection,
including anyone
who asks for the
test. Medicare covers
this test once every
12 months or up to
three times during a
pregnancy.
Page 8 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Preventive –B
reast Cancer 100% for all preventive 100% for all preventive 60% after $300
Services Screening services covered under services covered under combined annual
(Continued) (Mammogram). Original Medicare. Original Medicare at deductible
Medicare covers zero cost sharing.
screening Any additional Immunizations
mammograms once preventive services Any additional covered at 100%
every 12 months approved by Medicare preventive services
for all women with mid-year will be approved by Medicare Smoking and Tobacco
Medicare age 40 covered by Original mid-year will be Use Cessation covered
and older. Medicare Medicare. covered by the plan or at 50% after $300
covers one baseline by Original Medicare. combined annual
mammogram for deductible
women between Plan covers a physical
ages 35-39. exam annually.
–M
edical Nutrition
Therapy Services
Nutrition therapy
is for people who
have diabetes or
kidney disease (but
aren’t on dialysis or
haven’t had a kidney
transplant) when
referred by a doctor.
These services can be
given by a registered
dietitian and may
include a nutritional
assessment and
counseling to help
you manage your
diabetes or kidney
disease.
– P ersonalized
Prevention Plan
Services (Annual
Wellness Visits)
– P neumococcal
Vaccine. You may
only need the
Pneumonia vaccine
once in your lifetime.
Call your doctor for
more information.
Page 9 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Preventive – P rostate Cancer 100% for all preventive 100% for all preventive 60% after $300
Services Screening services covered under services covered under combined annual
(Continued) Original Medicare. Original Medicare at deductible
– P rostate Specific
zero cost sharing.
Antigen (PSA) test
Any additional Immunizations
only. Covered once a
preventive services Any additional covered at 100%
year for all men with
approved by Medicare preventive services
Medicare over age
mid-year will be approved by Medicare Smoking and Tobacco
50.
covered by Original mid-year will be Use Cessation covered
– S moking and Medicare. covered by the plan or at 50% after $300
Tobacco Use by Original Medicare. combined annual
Cessation deductible
(counseling to stop Plan covers a physical
smoking and tobacco exam annually.
use). Covered if
ordered by your
doctor. Includes two
counseling attempts
within a 12-month
period. Each
counseling attempt
includes up to four
face-to-face visits.
– S creening and
behavioral
counseling
interventions in
primary care to
reduce alcohol
misuse
– S creening for
depression in adults
– S creening for
sexually transmitted
infections (STI)
and high-intensity
behavioral
counseling to prevent
STIs
– I ntensive behavioral
counseling for
Cardiovascular
Disease (bi-annual)
– I ntensive behavioral
therapy for obesity
Page 10 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Preventive –W elcome to 100% for all preventive 100% for all preventive 60% after $300
Services Medicare Preventive services covered under services covered under combined annual
(Continued) Visits (initial Original Medicare. Original Medicare at deductible
preventive physical zero cost sharing.
exam). When you Any additional Immunizations
join Medicare Part B, preventive services Any additional covered at 100%
then you are eligible approved by Medicare preventive services
as follows; during mid-year will be approved by Medicare Smoking and Tobacco
the first 12 months covered by Original mid-year will be Use Cessation covered
of your new Part B Medicare. covered by the plan or at 50% after $300
coverage, you can by Original Medicare. combined annual
get either a Welcome deductible
to Medicare Plan covers a physical
Preventive Visits or exam annually.
an Annual Wellness
Visit. After your first
12 months, you
can get one Annual
Wellness Visit every
12 months.
Hospital Inpatient care at 100% after the 100% after $263 60% after $300
Services network hospitals following amounts for copayment per combined annual
(semiprivate room, each benefit period day (days 1-7) per deductible (1)
ancillary services, - $1,184 deductible admission; 100% after
physician visits) for days 1-60; $296 day 7 (1)
copayment per day
(days 61-90); $592
copayment per lifetime
reserve day (days 91-
150) (2)
Outpatient nonsurgical 80% after $147 100% per visit after 60% after $300
services deductible $50-$263 copayment; combined annual
or 80% after 20% deductible
coninsurance (based on
services received)
Outpatient surgical 80% after $147 100% per visit after 60% after $300
services deductible $263 copayment combined annual
deductible
Emergency care 80% after $147 100% per visit after 100% per visit after
(emergency room, deductible and $65 copayment $65 copayment
emergency services) emergency room (waived if admitted (waived if admitted
copayment (waived if within 24 hours) within 24 hours)
admitted to hospital
within 3 days of
emergency room visit)
Page 11 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Additional Ambulatory surgical 80% after $147 100% per visit after 60% after $300
Medical center deductible $150 copayment combined annual
Services deductible
Immediate care 80% after $147 100% per visit $35 60% after $300
facility deductible copayment combined annual
deductible
Ambulance 80% after $147 100% after $250 100% after $250
deductible copayment per date copayment per date
of service of service
Physical, respiratory, 80% after $147 100% per visit after 60% after $300
audiology, cardiac, deductible $35-$75 copayment combined annual
occupational or (based on where deductible
speech therapy services are received)
Home health services 100% 100% 80% after $300
combined annual
deductible
Durable medical 80% after $147 80% 65% after $300
equipment (includes deductible combined annual
oxygen received from deductible
a durable medical
equipment provider
or a pharmacy)
Diabetic monitoring 80% after $147 90%-100% (based 60% after $300
supplies deductible on where services are combined annual
received) deductible
Renal dialysis 80% after $147 80%-100% (based 80%-100% after $300
deductible on where services are combined annual
received) deductible (based on
where services are
received)
Skilled nursing facility 100% for days 1-20 100% for days 1-10; 60% after $300
(3-day hospital stay 100% after $25 combined annual
required); 100% after copayment per day deductible up to 100
$148 copayment per (days 11-21); 100% days; per benefit
day (days 21-100); per after $150 copayment period (1), (2)
benefit period (2) per day (days 22-100);
per benefit period (1),
(2)
Page 12 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Mental and Inpatient care at 100% after the 100% after $210 60% after $300
Nervous network hospitals following amounts for copayment per day combined annual
Disorder (semiprivate room, each benefit period (days 1-7) per deductible (1)
Services ancillary services, - $1,184 deductible admission; 100%
physician visits) for days 1-60; $296 after day 7 (1)
(190-day lifetime copayment per day
maximum in a (days 61-90); $592
psychiatric hospital) copayment per lifetime
reserve day (days 91-
150) (2)
Outpatient 65% after $147 100% per visit after 60% after $300
deductible $15-$75 copayment combined annual
(based on where deductible
services are received)
Alcohol and Inpatient care at 100% after the 100% after $210 60% after $300
Substance network hospitals following amounts for copayment per day combined annual
Abuse (semiprivate room, each benefit period (days 1-7) per deductible (1)
Services ancillary services, - $1,184 deductible admission; 100%
physician visits) for days 1-60; $296 after day 7 (1)
copayment per day
(days 61-90); $592
copayment per lifetime
reserve day (days 91-
150) (2)
Outpatient 80% after $147 100% per visit after 60% after $300
deductible $15-$75 copayment combined annual
(based on where deductible
services are received)
Page 13 of 16Humana Medicare Humana Medicare
Employer PPO (for Employer PPO (for
Services Provided by Services Provided by
Original Medicare an In-Network an Out-of-Network
Benefit Plan* Pays: Provider) Pays: Provider) Pays:
Prescription Prescription drugs 80% after $147 80% 60% after $300
Drugs covered under Part B deductible combined annual
deductible
Prescription drugs Most drugs are not If your plan provides Part D prescription drug
covered under Part D covered under Original coverage, please see attached Prescription Drug
Medicare Schedule
*This Summary of Benefits includes the 2013 Medicare cost sharing amounts and will change
effective January 1, 2014. Social Security will notify you of the new 2014 Medicare Part B
premium, deductible and Part A cost sharing amounts prior to January 1, 2014.
Benefits apply to Medicare-covered services only and costs are calculated using Medicare-
approved amounts. Please see your Evidence of Coverage for a complete list of covered
benefits. You may also choose to contact Humana to confirm that planned inpatient services
are Medicare-covered services and therefore covered by your plan. Please refer to the customer
service number on the back of your ID card.
(1) Inpatient hospital admissions, except in emergency or urgently needed care situations, require
prior authorization from Humana.
(2) A “benefit period” starts the day you go into the hospital or skilled nursing facility. It ends when
you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after
one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital
deductible for each benefit period. There is no limit to the number of benefit periods you have.
Page 14 of 16These Services are not
Health and Wellness offered by Original
Programs Medicare You Pay Nothing for these Programs
Extra SilverSneakers ®
This benefit is not Available to all members except for those who
Benefits offered live in Alaska, Connecticut or Massachusetts
Humana Active This benefit is not Health and wellness education available to all
Outlook SM
offered Humana Medicare Advantage members
HumanaFirst ®
This benefit is not A toll-free 24-hour, 7-day-a-week medical
offered information service with specially trained
registered nurses to answer questions on
symptom-related health conditions
Well Dine Inpatient This benefit is not After your overnight stay in a hospital or nursing
Meal Program offered facility, you are eligible for ten nutritious,
precooked frozen meals delivered to your door at
no cost to you
QuitNet®
This benefit is not Smoking cessation service available to all
offered Humana Medicare Advantage members through
QuitNet®
Over-the Counter This benefit is not You are eligible to receive a $20 monthly benefit
Items offered toward the purchase of selected over-the-
counter items such as vitamins, pain relievers,
cough and cold medicines, allergy medications,
and first aid/medical supplies when you
use Humana’s mail order service. For more
information or to request an order form, please
contact the Customer Care number on the back of
your ID card.
Page 15 of 16Humana is a Medicare Advantage organization with a Medicare contract. You must continue to pay your Medicare
Part B premiums. This is an advertisement. The benefit information provided herein is a brief summary, not a
comprehensive description of benefits. For more information contact the plan. Limitations, copayments and
restrictions may apply. Benefits, premium and/or copayments/coinsurance may change each year.
Humana.com
(Pending CMS Approval) PPO 079/084You can also read
