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HumanaChoice Giveback H5216-138 (PPO)

New Hampshire Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost
$0
by Humana

Additional Coverage

HearingVisionDental

Overall Government Star Rating

 3.5
out of 5 stars

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Plan Overview

Plan Name
HumanaChoice Giveback H5216-138 (PPO)
Insurance Carrier
Humana
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
PPO

HumanaChoice Giveback H5216-138 (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in New Hampshire and offered by the health insurance company Humana. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.

Cost Summary

Monthly Premium
$0
Annual Deductible
$540 annual deductible
Max Out-of-Pocket
$5,200
Primary doctor visit
$0 copay
Specialist visit
$50 copay per visit
ER visit
$125 copay per visit (always covered)
Ambulance
$315 copay

HumanaChoice Giveback H5216-138 (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $540 annual deductible and a maximum out of pocket cost sharing of $7,750 In and Out-of-network $5,200 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for HumanaChoice Giveback H5216-138 (PPO) are defined below.

Additional Benefits and Coverage

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

HumanaChoice Giveback H5216-138 (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. HumanaChoice Giveback H5216-138 (PPO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. HumanaChoice Giveback H5216-138 (PPO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Limited coverage
Over the counter drug benefits
Not covered
In-home support services
Not covered
Home and bathroom safety devices
Not covered
Meals for short duration
Limited coverage
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Comparing the Quality Score of HumanaChoice Giveback (PPO) to Other Plans in New Hampshire

Each year the federal government evaluates the quality of Medicare Advantage and Part D Prescription Drug plans based on a 5-star scoring system. For 2025, HumanaChoice Giveback (PPO) received an overall government quality rating of 3.5 stars out of 5 stars.

HumanaChoice Giveback (PPO) performed better than New Hampshire’s State average overall quality score of 3.4 stars.

This Plan’s 5-star Gov’t Quality Score
New Hampshire State Average Score
Overall Government 5 Star Quality Rating
 3.5
 3.4
Summary rating of health plan quality
 3.5
 3.4
Staying healthy: screenings, tests, & vaccines
 4
 3.4
Managing chronic (long term) conditions
 4
 3.2
Member experience with health plan
 4
 3.1
Member complaints & changes in the health plan's performance
 4
 4.1
Health plan customer service
 4
 4.1
Summary rating of drug plan quality
 3.5
 3.7
Drug plan customer service
 4
 4.2
Member complaints & changes in the drug plan's performance
 3
 4.0
Member experience with the drug plan
 4
 3.3
Drug safety & accuracy of drug pricing
 3
 3.4

The government calculates an “Overall star rating” based on ratings for sub components including “Health plan star rating” and “Drug plan star rating”, which includes further subcomponents of each.

HumanaChoice Giveback (PPO) received 3.5 stars for its health plan quality score which is better than the New Hampshire State average health plan quality score of 3.4 stars.

HumanaChoice Giveback (PPO) received 3.5 stars for its drug plan quality score which is worse than the New Hampshire State average drug plan quality score of 3.7 stars.

Plan Benefits and Coverage Details

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$540 annual deductible
Health Plan Max Out-of-Pocket
$7,750 In and Out-of-network
$5,200 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes
Doctor Lookup Link
https://www.humana.com/medicare?cm_mmc=provider_Medicare_gov-_-Medicare_gov_link-_-Vanity-_-Link
Plan Link
http://www.humana.com/medicare

Medical Benefits

Doctor Services

Primary doctor visit
In-network: $0 copay
Out-of-network: $45 copay per visit
Specialist visit
In-network: $50 copay per visit
Out-of-network: $65 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
In-network: $0-100 copay
Out-of-network: $45-65 copay or 40% coinsurance
Lab services
In-network: $0-55 copay
Out-of-network: $45-65 copay or 40% coinsurance
Diagnostic radiology services (like MRI)
In-network: $50-400 copay
Out-of-network: $65 copay or 40% coinsurance
Outpatient x-rays
In-network: $0-130 copay
Out-of-network: $45-65 copay or 40% coinsurance
Emergency care
$125 copay per visit (always covered)
Urgent care
$55 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
In-network: $445 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond
Out-of-network: $445 per day for days 1 through 7
$0 per day for days 8 through 90
Outpatient hospital coverage
In-network: $50-550 copay per visit
Out-of-network: 40% coinsurance per visit

Skilled nursing facility

Skilled nursing facility
In-network: $10 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 40% per stay

Preventive services

Preventive services
In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance
In-network: $315 copay
Out-of-network: $315 copay

Therapy services

Occupational therapy visit
In-network: $40 copay
Out-of-network: 40% coinsurance
Physical therapy & speech & language therapy visit
In-network: $40 copay
Out-of-network: 40% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist
In-network: $45 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $45 copay
Out-of-network: 40% coinsurance
Outpatient group therapy visit
In-network: $45 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy visit
In-network: $45 copay
Out-of-network: 40% coinsurance

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
In-network: 4% coinsurance per item
Out-of-network: 20% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 9% coinsurance per item
Out-of-network: 20% coinsurance per item
Diabetes supplies
In-network: $0 copay or 4-10% coinsurance per item
Out-of-network: 40% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$0.00 copay$0 copay
Generic$5.00 copay$0 copay
Preferred Brand$47.00 copay$0 copay
Non-Preferred Drug50% coinsurance$0 copay
Specialty Tier28% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 20% coinsurance

Extra Benefits

Hearing

Hearing exam
In-network: $50 copay
Out-of-network: $65 copay
Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - All types
In-network: $699-999 copay
Out-of-network: $699-999 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
Not covered
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
Not covered
Endodontics
Not covered
Periodontics
Not covered
Prosthodontics, removable
Not covered
Prosthodontics, fixed
Not covered
Maxillofacial prosthetics
Not covered
Implant services
Not covered
Oral and maxillofacial surgery
Not covered
Orthodontics
Not covered
Adjunctive general services
In-network: $0 copay
Out-of-network: $0 copay

Vision

Routine eye exam
In-network: $0 copay
Out-of-network: $0 copay
Contact lenses
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses (frames & lenses)
In-network: $0 copay
Out-of-network: $0 copay
Eyeglass frames (only)
Not covered
Eyeglass lenses (only)
Not covered
Upgrades
Not covered

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