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{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H1036235000SB23 Summary of Benefits 9H1036235000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•$0 copay for each Advanced level hearing aid up to 1per ear every
3years.
Hearing aid purchase includes: |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•$0 copay for each Advanced level hearing aid up to 1per ear every
3years.
Hearing aid purchase includes:
•Unlimited follow-up provider visits during first year following
TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call
1-844-255-7144 to schedule an appointment (for TTY, dial 711).
DENTAL SERVICES
Medicare-covered dental $0 copay
Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approve
coverage. Dental benefits under |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approve
coverage. Dental benefits under
this plan may not cover all
American Dental Association
procedure codes. Information
regarding each plan is available
at Humana.com/sb .
Network dentists have agreed to
provide services at contracted
fees (the in-network fee
schedules, or INFS). If amember
visits aparticipating network
dentist, the member will not |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Network dentists have agreed to
provide services at contracted
fees (the in-network fee
schedules, or INFS). If amember
visits aparticipating network
dentist, the member will not
receive abill for charges more
than the negotiated fee schedule
on covered services (coinsurance
payment still applies).
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at DEN142 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | on covered services (coinsurance
payment still applies).
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at DEN142
•$0 copay for scaling and root planing (deep cleaning) up to 1per
quadrant every 3years.
•$0 copay for comprehensive oral evaluation or periodontal exam,
occlusal adjustment, scaling for moderate inflammation up to 1
every 3years.
•$0 copay for bridges, complete dentures, crown recementation, |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | occlusal adjustment, scaling for moderate inflammation up to 1
every 3years.
•$0 copay for bridges, complete dentures, crown recementation,
denture recementation, panoramic film or diagnostic x-rays, partial
dentures up to 1every 5years.
•$0 copay for crown, root canal, root canal retreatment up to 1per
tooth per lifetime.
•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year.
•$0 copay for adjustments to dentures, denture rebase, denture |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | tooth per lifetime.
•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year.
•$0 copay for adjustments to dentures, denture rebase, denture
reline, denture repair, emergency diagnostic exam, tissue
conditioning up to 1per year.
•$0 copay for emergency treatment for pain, fluoride treatment, oral
surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year.
•$0 copay for periodontal maintenance up to 4per year.
•$0 copay for amalgam and/or composite filling, necessary |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year.
•$0 copay for periodontal maintenance up to 4per year.
•$0 copay for amalgam and/or composite filling, necessary
anesthesia with covered service, simple or surgical extraction up to
unlimited per year.
•$5000 maximum benefit coverage amount per year for preventive
and comprehensive benefits. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | and comprehensive benefits. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
10 Summary of Benefits H1036235000SB23 H1036235000
Covered Medical and Hospital Benefits (cont.) |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | plan .
c
10 Summary of Benefits H1036235000SB23 H1036235000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
Humana.com >Find aDoctor >
from the Search Type drop down
select Dental >under Coverage
type select All Dental Networks >
enter zip code >from the
network drop down select
HumanaDental Medicare.
VISION SERVICES
Medicare-covered vision
services $0 copay
Medicare-covered diabetic eye
exam $0 copay
Medicare-covered glaucoma
screening $0 copay |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | network drop down select
HumanaDental Medicare.
VISION SERVICES
Medicare-covered vision
services $0 copay
Medicare-covered diabetic eye
exam $0 copay
Medicare-covered glaucoma
screening $0 copay
Medicare-covered eyewear
(post-cataract) $0 copay
Routine vision
The provider locator for routine
vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS733
•$0 copay for routine exam up to 1per year. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS733
•$0 copay for routine exam up to 1per year.
•$300 maximum benefit coverage amount per year for contact
lenses or eyeglasses-lenses and frames, fitting for
eyeglasses-lenses and frames.
•Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per
year. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | •Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per
year.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $0 copay
Outpatient group and individual
therapy visits $0 copay
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay
PHYSICAL THERAPY |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | health care in apsychiatric
hospital $0 copay
Outpatient group and individual
therapy visits $0 copay
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay
PHYSICAL THERAPY
N/A $0 copay You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H1036235000SB23 Summary of Benefits 11 H1036235000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
AMBULANCE
Ambulance $0 copay
TRANSPORTATION
N/A $0 copay for plan approved location up to 24 one-way trip(s) per year. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | N/A WHAT YOU PAY ON THIS HUMANA PLAN
AMBULANCE
Ambulance $0 copay
TRANSPORTATION
N/A $0 copay for plan approved location up to 24 one-way trip(s) per year.
This benefit is not to exceed 50 miles per trip.
The member must contact transportation vendor to arrange
transportation and should contact Customer Care to be directed to
their plan's specific transportation provider.
MEDICARE PART BDRUGS
Chemotherapy drugs $0 copay
Other Part Bdrugs $0 copay
Prescription Drug Benefits
PRESCRIPTION DRUGS |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | their plan's specific transportation provider.
MEDICARE PART BDRUGS
Chemotherapy drugs $0 copay
Other Part Bdrugs $0 copay
Prescription Drug Benefits
PRESCRIPTION DRUGS
Medicare Part DDrugs See chart below for plan coverage information for
prescription drugs
$0 Rx Copay Benefit If you qualify for "Extra Help", you will pay $0 for all Medicare Part Dcovered
prescription drugs on your formulary, for all tiers, and through all stages.
Pharmacy options
Mail Order Mail Order cost-sharing |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | prescription drugs on your formulary, for all tiers, and through all stages.
Pharmacy options
Mail Order Mail Order cost-sharing
$0 CenterWell Pharmacy ™,
Walmart Mail ,PillPack
Other pharmacies are available in
our network. To find pharmacy
mail order options go to
Humana.com/pharmacyfinder
Retail Retail cost-sharing All network retail pharmacies
For generic drugs (including 30-day supply 90-day supply*
brand drugs treated as generic),
either: $0 $0
For all other drugs ,either: $0 $0 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Retail Retail cost-sharing All network retail pharmacies
For generic drugs (including 30-day supply 90-day supply*
brand drugs treated as generic),
either: $0 $0
For all other drugs ,either: $0 $0
Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply 12 Summary of Benefits H1036235000SB23 H1036235000 To find out if you qualify for "Extra Help," please contact the Social Security Office at 1-800-772-1213 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | *Some drugs are limited to a30-day supply 12 Summary of Benefits H1036235000SB23 H1036235000 To find out if you qualify for "Extra Help," please contact the Social Security Office at 1-800-772-1213
Monday —Friday, 7a.m. —7p.m. TTY users should call 1-800-325-0778. For more information on
pharmacy-specific cost-sharing, please call us or refer to Chapter 6of the Evidence of Coverage for more
details.
If you reside in along-term care facility, you pay the same as at aretail pharmacy. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | pharmacy-specific cost-sharing, please call us or refer to Chapter 6of the Evidence of Coverage for more
details.
If you reside in along-term care facility, you pay the same as at aretail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy.
Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,400 ,you pay nothing for all drugs. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,400 ,you pay nothing for all drugs.
Additional Benefits
N/A WHAT YOU PAY ON THIS HUMANA PLAN
Medicare-covered foot care
(podiatry) $0 copay
Medicare-covered chiropractic
services $0 copay
MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment
(like wheelchairs or oxygen) $0 copay
Medical Supplies $0 copay
Prosthetics (artificial limbs or |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicare-covered chiropractic
services $0 copay
MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment
(like wheelchairs or oxygen) $0 copay
Medical Supplies $0 copay
Prosthetics (artificial limbs or
braces) $0 copay
Diabetic monitoring supplies $0 copay
REHABILITATION SERVICES
Occupational and speech
therapy $0 copay
Cardiac rehabilitation $0 copay
Pulmonary rehabilitation $0 copay
TELEHEALTH SERVICES (in addition to Original Medicare)
Primary care provider (PCP) $0 copay
Specialist $0 copay |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | therapy $0 copay
Cardiac rehabilitation $0 copay
Pulmonary rehabilitation $0 copay
TELEHEALTH SERVICES (in addition to Original Medicare)
Primary care provider (PCP) $0 copay
Specialist $0 copay
Urgent care services $0 copay
Substance abuse or behavioral
health services $0 copay H1036235000SB23 Summary of Benefits 13 H1036235000
Medicaid Benefit Comparison
The benefits described in the Covered Medical and Hospital Benefits sections above are covered by |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicaid Benefit Comparison
The benefits described in the Covered Medical and Hospital Benefits sections above are covered by
Humana Community HMO SNP-DE (HMO D-SNP). Below is acomparison of benefits that some Medicaid
eligible individuals could receive directly from the Kentucky Department of Medicaid Services (DMS). For
each benefit listed below, you can see what the Kentucky Department of Medicaid Services (DMS) covers |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | each benefit listed below, you can see what the Kentucky Department of Medicaid Services (DMS) covers
and what our plan covers. All Medicaid benefits are subject to Medicaid eligibility guidelines and
requirements, and are available only to full dual eligible individuals. If you have questions about your
Medicaid eligibility and what benefits you are entitled to, review your member handbook or contact the
Kentucky Department of Medicaid Services (DMS) at 1-800-635-2570. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicaid eligibility and what benefits you are entitled to, review your member handbook or contact the
Kentucky Department of Medicaid Services (DMS) at 1-800-635-2570.
BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT
Acute inpatient hospital care Covered Covered
Ambulance Covered Covered
Ambulatory surgical center Covered Covered
Dentures Not Covered Covered
Diagnostic
services/labs/imaging Covered Covered
Doctor office visits (Primary
care provider (PCP)/specialists Covered Covered |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Ambulatory surgical center Covered Covered
Dentures Not Covered Covered
Diagnostic
services/labs/imaging Covered Covered
Doctor office visits (Primary
care provider (PCP)/specialists Covered Covered
Emergency care Covered Covered
Eyeglasses Not Covered Covered
Hearing aids Not Covered Covered
Home and community based
waiver service programs Covered Not Covered
Inpatient hospital, nursing
facility and intermediate care
facility services in institutions
for mental diseases (MD), age |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Home and community based
waiver service programs Covered Not Covered
Inpatient hospital, nursing
facility and intermediate care
facility services in institutions
for mental diseases (MD), age
65 and older Covered Covered with limitations
Inpatient psychiatric services,
under age 21 Covered Covered with limitations
Intermediate care facility for
intellectual disabilities
(ICF-IDD) Covered Not Covered
Intermediate care facility
services for individuals with |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | under age 21 Covered Covered with limitations
Intermediate care facility for
intellectual disabilities
(ICF-IDD) Covered Not Covered
Intermediate care facility
services for individuals with
intellectual disabilities Covered Covered with limitations 14 Summary of Benefits H1036235000SB23 H1036235000
BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT
Mental health services
(outpatient group therapy and
individual therapy visit) Covered Covered
Nursing facility services, other |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT
Mental health services
(outpatient group therapy and
individual therapy visit) Covered Covered
Nursing facility services, other
than in an institution for mental
diseases Covered Covered with limitations
Outpatient hospital coverage Covered Covered
Personal emergency response
system (PERS) Not Covered Covered
Physical therapy Covered Covered
Prescription drugs –Medicare
Part Bdrugs Covered Covered
Prescription drugs –outpatient |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Personal emergency response
system (PERS) Not Covered Covered
Physical therapy Covered Covered
Prescription drugs –Medicare
Part Bdrugs Covered Covered
Prescription drugs –outpatient
prescription drugs; Medicare
covered &non-Medicare
covered Covered Covered
Preventive care (e.g., flu
vaccine, diabetic screenings) Covered Covered
Routine non-emergency medical
transportation Covered Covered
Skilled nursing facility Covered Covered |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Preventive care (e.g., flu
vaccine, diabetic screenings) Covered Covered
Routine non-emergency medical
transportation Covered Covered
Skilled nursing facility Covered Covered
Urgently needed services Covered Covered H1036235000SB23 Summary of Benefits 15 H1036235000
More benefits with your plan
Enjoy some of these extra benefits included in your plan .
This is asummary of what we cover. It doesn't list every service that we cover or list |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | More benefits with your plan
Enjoy some of these extra benefits included in your plan .
This is asummary of what we cover. It doesn't list every service that we cover or list
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of
coverage and services. Visit Humana.com/medicare to view acopy of the EOC or call
1-800-833-2364 .
Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | 1-800-833-2364 .
Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and
comprehensive dental, vision, or hearing
services including copays.
Members can use this benefit at
participating providers where the
primary business is Dental Care, Vision
Services, or Hearing Services and Visa®
is accepted.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Services, or Hearing Services and Visa®
is accepted.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year.
Allowance amounts cannot be
combined with other benefit allowances.
Limitations and restrictions may apply.
Humana Healthy Options Allowance
$150 automatically loaded on aprepaid
card every month to use toward the
purchase of food, over-the-counter
(OTC) products, and home supplies from |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Humana Healthy Options Allowance
$150 automatically loaded on aprepaid
card every month to use toward the
purchase of food, over-the-counter
(OTC) products, and home supplies from
anational network of retailers. The card
may also be used to pay for
non-medical transportation, general
supports for living (such as rent
assistance, internet, and utilities), social
needs, aging support and assistive
devices, pest control, and pet care and
supplies. Unused funds will roll over to |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | supports for living (such as rent
assistance, internet, and utilities), social
needs, aging support and assistive
devices, pest control, and pet care and
supplies. Unused funds will roll over to
the next month and expire at the end of
the plan year. Allowance amounts
cannot be combined with other benefit
allowances. Limitations and restrictions
may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | allowances. Limitations and restrictions
may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other
allowance listed. Allowances shown are
accessed by using this card. Allowance
amounts cannot be combined with
other benefit allowances. Limitations
and restrictions may apply.
*Healthy Options Allowance
*Humana Flex Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | other benefit allowances. Limitations
and restrictions may apply.
*Healthy Options Allowance
*Humana Flex Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana
Flexible Care Assistance
Humana Flexible Care Assistance is
available to members with chronic
health conditions, who are participating
in care management services, and meet
program criteria. Eligible members may
receive medical expense assistance and
other additional benefits, either |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | health conditions, who are participating
in care management services, and meet
program criteria. Eligible members may
receive medical expense assistance and
other additional benefits, either
primarily health related or non-primarily
health related, to address the member's
unique individual needs. Benefits are
limited up to $1,000 per year and must
be coordinated and authorized by acare
manager. There is no cost to participate.
Acupuncture
$0 copay for acupuncture visits up to 12 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | limited up to $1,000 per year and must
be coordinated and authorized by acare
manager. There is no cost to participate.
Acupuncture
$0 copay for acupuncture visits up to 12
visit(s) per year.
Chiropractic services
Routine chiropractic:
$0 copay per visit for up to 12 visits. 16 Summary of Benefits H1036235000SB23 H1036235000
Smoking cessation program
To further assist in your effort to quit
smoking or tobacco product use, we
cover one additional counseling quit |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Smoking cessation program
To further assist in your effort to quit
smoking or tobacco product use, we
cover one additional counseling quit
attempt within a12-month period as a
service with no cost to you. This is in
addition to the two counseling attempts
provided by Medicare and includes up to
four face-to-face visits. This service can
be used for either preventive measures
or for diagnosis with atobacco related
disease.
Routine foot care
$0 copay per visit for up to 6visits
Papa Pals |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | four face-to-face visits. This service can
be used for either preventive measures
or for diagnosis with atobacco related
disease.
Routine foot care
$0 copay per visit for up to 6visits
Papa Pals
$0 copayment for members to be
connected with atrusted college
student that offers assistance with
other instrumental activities of daily
living (IADLs). Support may be in person
or virtually for up to 60 hours per year
(minimum of one hour per visit).
Humana Well Dine ®Meal Program |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | other instrumental activities of daily
living (IADLs). Support may be in person
or virtually for up to 60 hours per year
(minimum of one hour per visit).
Humana Well Dine ®Meal Program
Humana's meal program for members
with certain special needs plan (SNP)
specific conditions or following an
inpatient stay in the hospital or nursing
facility.
Personal Emergency Response
System
The personal emergency response
system provides help in emergency
situations. On The Go Mobile personal |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | inpatient stay in the hospital or nursing
facility.
Personal Emergency Response
System
The personal emergency response
system provides help in emergency
situations. On The Go Mobile personal
help button or an On the Go Mobility
personal help button, both function in
and out of the home. On The Go uses
two way voice communication &five
location seeking technologies to send
help quickly to wherever the member is
located. On the Go Mobility personal
help button offers fall detection |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | two way voice communication &five
location seeking technologies to send
help quickly to wherever the member is
located. On the Go Mobility personal
help button offers fall detection
remotely activated/deactivated, up to 5
days of battery life, location services,
and wandering. Personal Home Care
$0 copay for aminimum of 4hours per
day, up to amaximum of 80 hours per
year for certain in-home support
services to assist individuals with
disabilities and/or medical conditions in |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | $0 copay for aminimum of 4hours per
day, up to amaximum of 80 hours per
year for certain in-home support
services to assist individuals with
disabilities and/or medical conditions in
performing activities of daily living
(ADLs) and Instrumental Activities of
Daily living (IADLs) within the home by a
qualified aide. Amember must be
receiving assistance with aminimum of
one ADL to receive assistance with any
IADL.
Authorization may be required. Contact
the plan for details. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | qualified aide. Amember must be
receiving assistance with aminimum of
one ADL to receive assistance with any
IADL.
Authorization may be required. Contact
the plan for details.
Rewards and Incentives
Go365 by Humana ®aRewards and
Incentive program for completing
certain preventive health screenings and
health and wellness activities.
Wigs (related to chemotherapy
treatment)
Up to an unlimited maximum benefit
per year.
SilverSneakers ®fitness program
Basic fitness center membership |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | health and wellness activities.
Wigs (related to chemotherapy
treatment)
Up to an unlimited maximum benefit
per year.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 17
H1036_SB_MAPD_HMO_235000_2023_M Summary of Benefits H1036235000SB23 To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You”
handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227),
24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as aSpecial
Needs Plan (SNP) until 12/31/2023 based on areview of Humana's Model of Care.
Your provider may choose to submit to the Kentucky Department of Medicaid Services (DMS) for consideration of |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Needs Plan (SNP) until 12/31/2023 based on areview of Humana's Model of Care.
Your provider may choose to submit to the Kentucky Department of Medicaid Services (DMS) for consideration of
additional secondary payment for an amount applied to deductibles, coinsurance, or copayments. If you are Cost
Share Protected, providers are required by federal regulation to accept Humana Community HMO SNP-DE (HMO |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Share Protected, providers are required by federal regulation to accept Humana Community HMO SNP-DE (HMO
D-SNP) primary payment and the Kentucky Department of Medicaid Services (DMS) secondary payment as
payment in full for covered Medicare Part Aand Part Bservices –even when the Medicaid payment is zero or a
provider chooses to not submit to Medicaid.
If you are cost-share protected by the Kentucky Department of Medicaid Services (DMS), Humana Community |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | provider chooses to not submit to Medicaid.
If you are cost-share protected by the Kentucky Department of Medicaid Services (DMS), Humana Community
HMO SNP-DE (HMO D-SNP) providers aren't allowed to collect or bill you for services and items covered under
Medicare Part Aand Part B, including deductibles, coinsurance, and copayments –even when Medicaid payment
is zero or aprovider chooses to not submit to Medicaid. If aprovider asks you to pay, that's against the law. You |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | is zero or aprovider chooses to not submit to Medicaid. If aprovider asks you to pay, that's against the law. You
may however be responsible for asmall Medicaid copayment.
If you are cost-share protected and you are billed or asked to pay the provider for deductibles, coinsurance, or
copayments on covered Medicare Part Aand Part Bservices tell your provider you are cost-share protected and |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | copayments on covered Medicare Part Aand Part Bservices tell your provider you are cost-share protected and
can't be charged. If you have already made payment you have the right to arefund. If your provider will not stop
billing, you can call us at 1-800-457-4708 or you can call Medicare at 1-800-Medicare (1-800-633-4227), (TTY
1-877-486-2048). Humana or Medicare can ask your provider to stop billing you and refund any payment you
have made. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | 1-877-486-2048). Humana or Medicare can ask your provider to stop billing you and refund any payment you
have made.
Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different
for Original Medicare telehealth.
Limitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services
are not asubstitute for emergency care and are not intended to replace your primary care provider or other |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | are not asubstitute for emergency care and are not intended to replace your primary care provider or other
providers in your network. Any descriptions of when to use telehealth services are for informational purposes only
and should not be construed as medical advice. Please refer to your evidence of coverage for additional details
on what your plan may cover or other rules that may apply. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | and should not be construed as medical advice. Please refer to your evidence of coverage for additional details
on what your plan may cover or other rules that may apply.
Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. You can see our plan's provider and pharmacy directory at our website at
humana.com/finder/search or call us at the number listed at the beginning of
this booklet and we will send you one. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | humana.com/finder/search or call us at the number listed at the beginning of
this booklet and we will send you one.
You can see our plan's drug guide at our website at
humana.com/medicaredruglist or call us at the number listed at the beginning
of this booklet and we will send you one. Find out more Notes Notes 20 Summary of Benefits H1036235000SB23 H1036235000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | GHHLNNXEN 0522 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, national
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,
religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable
federal civil rights laws. If you believe that you have been discriminated against by Humana or its
subsidiaries, there are ways to get help.
•You may file acomplaint, also known as agrievance:
Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 . |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 .
•You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office
for Civil Rights electronically through their Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services , |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | for Civil Rights electronically through their Complaint Portal, available at
https://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: |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | •California residents: You may also call California Department of Insurance toll-free hotline number:
1-800-927-HELP (4357) ,to file agrievance.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711)
Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote
interpretation, and written information in other formats to people with disabilities when such auxiliary aids |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | interpretation, and written information in other formats to people with disabilities when such auxiliary aids
and services are necessary to ensure an equal opportunity to participate. H1036235000SB23 Summary of Benefits 21 H1036235000 22 Summary of Benefits H1036235000SB23 H1036235000 Humana Community HMO SNP-DE
(HMO D-SNP)
H1036235000 ENG
Jefferson County
Humana.com
GNHH4HIEN_23_C Summary of Benefits H1036235000SB23 |