Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H5216-428

Medicare Plan

HumanaChoice H5216-428 (PPO) · Humana · Local PPO · Select Counties in WA

Full CMS plan ID: H5216-428-001

H5216-428-001 is the full CMS identifier for the H5216-428 Medicare plan. Common searches include H5216 428 and H5216428.

Historical 2026 record. Benefits and service areas shown apply to that year.

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

HumanaChoice H5216-428 (PPO)

H5216-428-001 Select Counties in WA Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $495 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $2,475
02

Emergency transport

Ambulance

Ground · in-network$335 copay
Air · in-network$1,250 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$5,800
Combined in + out$10,100
05

Skilled care at home

Home health

In-network$0 copay
Out-of-network50% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-network$0 copay
Out-of-network50% coinsurance

Specialist

In-network$35 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–$50 copay
Out-of-network50% coinsurance

Laboratory services

In-network$0–$50 copay
Out-of-network50% coinsurance

X-rays & standard imaging

In-network$0–$780 copay
Out-of-network$0 copay + 50% coinsurance

MRI, CT & PET imaging

In-network20% 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$1,250 copay
Out-of-network$1,250 copay

Outpatient hospital

In-network$0–$495 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$45 copay
Out-of-network50% coinsurance

Physical & speech therapy

In-network$45 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$35 copay
Out-of-network50% coinsurance

Chiropractic

In-network$15 copay
Out-of-network50% coinsurance
Supplemental benefits7 benefits

Dental

In-network$35 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

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

In-network$0 copay
Out-of-network$0 copay
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$5,800
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

$5 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

25% retail coinsurance · 30-day supply

Using this plan

Understand H5216-428-001

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 H5216-428 (PPO) is a 2026 Local PPO offered by Humana in Select Counties in WA. 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 $2,475 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
$35 copay
Laboratory services
$0–$50 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$0–$50 copay
MRI, CT & PET imaging
20% coinsurance
Outpatient hospital
$0–$495 copay

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

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$2,475 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
Select Counties in WA (WA)
Plan type
Local PPO
Contract / plan
H5216-428
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$35 copay
Vision$0 copay
Hearing$0 copay
Over-the-counter allowance$0 copay
Fitness & wellness$0 copay
Meals$0 copay

Plan-specific answers

Frequently asked questions

Where is H5216-428-001 available?

HumanaChoice H5216-428 (PPO) is listed for Select Counties in WA (WA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H5216-428-001?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $5,800. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H5216-428-001?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H5216-428-001?

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

Does H5216-428-001 report extra benefits?

Yes. CMS reports dental, vision, hearing, over-the-counter allowance, fitness & wellness, and other supplemental benefits. 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 H5216-428-001 fits

Full CMS plan ID
H5216-428-001
Contract
H5216
Base plan code
H5216-428
Segment
001
Carrier
Humana
Plan type
Local PPO
Service area
Select Counties in WA (WA)

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.

  • Clark, WA
  • Cowlitz, WA
  • King, WA
  • Kitsap, WA
  • Pierce, WA
  • Snohomish, WA
  • Spokane, WA
  • Thurston, WA

Same CMS contract

H5216-428-002 HumanaChoice H5216-428 (PPO) Select Counties in OR · Local PPO H5216-428-003 HumanaChoice H5216-428 (PPO) Select Counties in UT · Local PPO H5216-428-005 HumanaChoice H5216-428 (PPO) Select Counties in OR · Local PPO H5216-048-000 HumanaChoice H5216-048 (PPO) Select Counties in ID, MT, OR, UT, WA, WY · Local PPO H5216-402-000 Humana Together in Health (PPO I-SNP) Select Counties in WA · Local PPO H5216-426-000 HumanaChoice H5216-426 (PPO) Select Counties in WA · Local PPO H5216-427-001 Humana USAA Honor Giveback (PPO) Select Counties in WA · Local PPO H5216-455-000 Humana USAA Honor Giveback (PPO) Select Counties in ID, OR, UT, WA · Local PPO

About this code

What H5216-428-001 identifies

H5216-428-001 is a Contract Year 2026 Medicare plan segment code. Searches written as H5216-428, H5216 428, or the compact full CMS ID H5216428001 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.