H5216-019 Medicare Plan (H5216-019-000)

● CMS 2026 plan record

HumanaChoice H5216-019 (PPO)

H5216-019-000 Kentucky, West Virginia, Indiana Local PPO

In-network

Inpatient hospital

Days 1–5 $450 / day

Days 6–90 $0 / day

Total of listed copays · 5 charged days $2,250

Emergency transport

Ambulance

Ground · in-network$335 copay

Air · in-network$335 copay

Emergency services

Emergency room

$130 copay

Waived if admitted within 24 hours

Medical maximum

Maximum out-of-pocket

In-network$6,550

Combined in + out$10,100

Skilled care at home

Home health

In-network$0 copay

Out-of-network50% coinsurance

Monthly cost

Premium & giveback

Part C premium$24 / month

Consolidated C + D$24 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-network$0 copay

Out-of-network50% coinsurance

Specialist

In-network$55 copay

Out-of-network50% coinsurance

Preventive care

In-network$0 copay

Out-of-network$0 copay + 50% coinsurance

Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-network$0–$105 copay

Out-of-network$50 copay + 50% coinsurance

Laboratory services

In-network$0–$50 copay

Out-of-network$50 copay + 50% coinsurance

X-rays & standard imaging

In-network$0–$780 copay

Out-of-network$0 copay + 50% coinsurance

MRI, CT & PET imaging

In-network$45 copay + 20% coinsurance

Out-of-network50% coinsurance

Urgent & hospital care6 benefits

Urgent care

In-networkCost share not reported

Out-of-networkNot separately reported

Emergency room

In-network$130 copay

Out-of-networkNot separately reported

Ground ambulance

In-network$335 copay

Out-of-network$335 copay

Air ambulance

In-network$335 copay

Out-of-network$335 copay

Outpatient hospital

In-network$0–$450 copay

Out-of-network$0 copay + 50% coinsurance

Outpatient surgery / ASC

In-network$0–$350 copay

Out-of-network$0 copay + 50% coinsurance

Recovery & therapy5 benefits

Home health

In-network$0 copay

Out-of-network50% coinsurance

Skilled nursing facility

In-networkCost share not reported

Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-network$10 copay

Out-of-network50% coinsurance

Occupational therapy

In-network$20–$40 copay

Out-of-network50% coinsurance

Physical & speech therapy

In-network$20–$40 copay

Out-of-network50% coinsurance

Behavioral health2 benefits

Mental health services

In-network$35 copay

Out-of-network50% coinsurance

Substance use treatment

In-network$35 copay

Out-of-network50% coinsurance

Specialty care2 benefits

Podiatry

In-network$55 copay

Out-of-network50% coinsurance

Chiropractic

In-network$15 copay

Out-of-network50% coinsurance

Supplemental benefits7 benefits

Dental

In-network$55 copay

Out-of-network50% coinsurance

Vision

In-network$0 copay

Out-of-network$0 copay

Hearing

In-network$0 copay

Out-of-network$0 copay

Transportation

Not reported in this CMS export

Fitness & wellness

In-network$0 copay

Out-of-network$0 copay

Over-the-counter allowance

In-network$0 copay

Out-of-network$0 copay

Meals

Not reported in this CMS export

Plan costs & rulesCoverage overview

Premium & Part B giveback

$24 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$6,550

Combined in + out$10,100

Medical deductibles

In-networkNot reported

Out-of-networkNot reported

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs5 tiers

Part D deductible

Not reported

Drug tier 1

$0 retail copay · 30-day supply

Drug tier 2

$10 retail copay · 30-day supply

Drug tier 3

$47 retail copay · 30-day supply

Drug tier 4

50% retail coinsurance · 30-day supply

Drug tier 5

30% retail coinsurance · 30-day supply

Using this plan

Understand H5216-019-000

Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

HumanaChoice H5216-019 (PPO) is a 2026 Local PPO offered by Humana in Kentucky, West Virginia, Indiana. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $2,250 across 5 charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician: $0 copay
Specialist: $55 copay
Laboratory services: $0–$50 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests: $0–$105 copay
MRI, CT & PET imaging: $45 copay + 20% coinsurance
Outpatient hospital: $0–$450 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room: $130 copay
Listed inpatient stages: $2,250 total

5 charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Availability

Who can enroll

Service area: Kentucky, West Virginia, Indiana (IN, KY, WV)
Plan type: Local PPO
Contract / plan: H5216-019
Coverage year: 2026

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

Dental$55 copay

Vision$0 copay

Hearing$0 copay

Over-the-counter allowance$0 copay

Fitness & wellness$0 copay

Plan-specific answers

Frequently asked questions

Where is H5216-019-000 available?

HumanaChoice H5216-019 (PPO) is listed for Kentucky, West Virginia, Indiana (IN, KY, WV). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H5216-019-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,550. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H5216-019-000?

The listed consolidated Part C and Part D premium is $24 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H5216-019-000?

The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.

Does H5216-019-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H5216-019-000 fits

Full CMS plan ID: H5216-019-000
Contract: H5216
Base plan code: H5216-019
Segment: 000
Carrier: Humana
Plan type: Local PPO
Service area: Kentucky, West Virginia, Indiana (IN, KY, WV)

County/service-area foundation

CMS service-area entries

Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.

Adams, IN
Allen, IN
Bartholomew, IN
Brown, IN
Cass, IN
Clark, IN
Crawford, IN
Daviess, IN
DeKalb, IN
Dubois, IN
Elkhart, IN
Floyd, IN

78 additional service-area entries are retained in the data record.

About this code

What H5216-019-000 identifies

H5216-019-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H5216-019, H5216 019, or the compact full CMS ID H5216019000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.

H5216-019

HumanaChoice H5216-019 (PPO)

Quick view

Inpatient hospital

Ambulance

Emergency room

Maximum out-of-pocket

Home health

Premium & giveback

Primary care physician

Specialist

Preventive care

Diagnostic procedures & tests

Laboratory services

X-rays & standard imaging

MRI, CT & PET imaging

Urgent care

Emergency room

Ground ambulance

Air ambulance

Outpatient hospital

Outpatient surgery / ASC

Home health

Skilled nursing facility

Cardiac & pulmonary rehabilitation

Occupational therapy

Physical & speech therapy

Mental health services

Substance use treatment

Podiatry

Chiropractic

Dental

Vision

Hearing

Transportation

Fitness & wellness

Over-the-counter allowance

Meals

All plan benefits

Primary care physician

Specialist

Preventive care

Diagnostic procedures & tests

Laboratory services

X-rays & standard imaging

MRI, CT & PET imaging

Urgent care

Emergency room

Ground ambulance

Air ambulance

Outpatient hospital

Outpatient surgery / ASC

Home health

Skilled nursing facility

Cardiac & pulmonary rehabilitation

Occupational therapy

Physical & speech therapy

Mental health services

Substance use treatment

Podiatry

Chiropractic

Dental

Vision

Hearing

Transportation

Fitness & wellness

Over-the-counter allowance

Meals

Premium & Part B giveback

Maximum out-of-pocket (MOOP)

Medical deductibles

Network & referrals

Part D deductible

Drug tier 1

Drug tier 2

Drug tier 3

Drug tier 4

Drug tier 5

Understand H5216-019-000

A quick read on this plan