Benefit	MSU Medicare Advantage Plan		MSU Non-Medicare Plan
	In-Network and Out-of-Network*		In-Network	Out-of-Network
Annual Deductible	Per member: $192 1		Individual: $100 Family: $200	Individual: $500 Family: $1,000
Fixed Dollar Copays	As noted on this page.		As noted on this page.	As noted on this page.
Percent Copays	As noted on this page.		As noted on this page.	As noted on this page.
Out-of-Pocket Maximum 2	Per member: $1,200 3		Individual: $3,000 4, 5 Family: $6,000 4, 5	Individual: $3,000 5, 6 Family: $6,000 5, 6
Transplant Maximum	No maximum		No maximum	No maximum

 

 

 

 

 

 

 

 

 

 

Footnotes:

1. Not all services are subject to the deductible. Refer to thetypeof service for benefit details.
2. Includes deductible, coinsurance and copays.
3. Per calendar year.
4. Per calendar year for medical services only.
5. Two separate limits apply to in-network and out-of-network services. Contact the provider for more information about out-of-network services.
6. Per calendar year for medical services and does not include copayments.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit1	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Health Maintenance Exam 2	Covered 100%	Covered 100%	Covered 90% 3
Annual Gynecological Exam 2	Covered 100%	Covered 100%	Covered 90% 3
Pap Smear Screening Lab services only	Covered 100% 4	Covered 100%	Covered 90% 3
Contraceptive Devices 5	Not a preventative service 6	Covered 100%	Covered 90% 3
Contraceptive Injections	Not a preventative service 6	Covered 100%	Covered 90% 3
Mammography Screening 2	Covered 100%	Covered 100%	Covered 90% 3
Immunizations 7	Covered 100%	Covered 100%	Covered 90% 3
Prostate Exam and Specific Antigen Test 2, 8	Covered 100%	Covered 100%	Covered 90% 3
Fecal Occult Blood Screening 2	Covered 100%	Covered 100%	Covered 90% 3
Preventative Colonoscopy	Covered 100% 4	Covered 100%	Covered 90% 3
Flexible Sigmoidoscopy Exam	Covered 100% 4	Covered 100%	Covered 90% 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Footnotes:

1. Preventive services are covered per the percentage noted, subject to the frequency and age limits as detailed in the Evidence of Coverage and Summary Plan Descriptions.
2. One per calendar year.
3. After deductible.
4. Every 24 months for preventative.
5. Includes IUD, diaphragm, and norplant (male contraceptives are not covered).
6. Covered at the applicable service or place of treatment cost share. 
7. Immunizations as recommended by the Advisory Committee on Immunization Practices or mandated by the Affordable Care Act. Coverage for immunizations on the MSU Medicare Advantage Plan is determined by whether it is Part B or Part D, which is decided by Medicare. If the immunization is Part D, such as Shingrix, it will have a copay, whereas Part B immunizations, such as influenza, are covered at 100%. For the MSU Non-Medicare Plan, immunization coverage is determined by the Affordable Care Act. Immunizations at a pharmacy usually result in the lowest cost to you and the pharmacy can verify coverage or other as applicable. 
8. Age limits may apply.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Office Visits/Consultations 1	Covered 96% 2	$20 Copay	Covered 90% 2

 

 

 

 

Footnotes:

1. Must be medically necessary.
2. After deductible.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit1	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Hospital Emergency Room	$50 Copay 2	$50 Copay 3	$50 Copay 3
Emergency Room Physician Services	Covered 100%	Covered 100%	Covered 100%
Urgent Care Center	Covered 96%	$25 Copay	$25 Copay
Ambulance Service 4	Covered 96% 5	Covered 80% 5	Covered 80% 5

 

 

 

 

 

 

 

Footnotes:

1. For those enrolled in the MSU Non-Medicare Plan only: If you are hospitalized in an out-of-network facility, Personify Health may require that you be transferred to an in-network facility as soon as you are stabilized. If you refuse you will be charged out-of-network from the date of stabilization.
2. Waived if admitted within 24 hours.
3. Waived if admitted during visit.
4. Must be medically necessary.
5. After deductible, ground and air.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Laboratory and Pathology Tests	Covered 100%	Covered 100% 1	Covered 90% 2
Diagnostic Tests and X-Rays 3	Covered 96-100% 4	Covered 100% 5	Covered 90% 2
Radiation Therapy	Covered 100% 4	Covered 100% 2	Covered 90% 2

 

 

 

 

 

 

Footnotes:

1. For outpatient and after deductible for inpatient.
2. After deductible.
3. Other than advanced imaging.
4. Prior authorization may be required.
5. After deductible, prior authorization may be required.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Pre-Natal and ost-Natal Care	Covered at the applicable service or place of treatment cost share.	Covered the same as other physican services	Covered the same as other physican services
Delivery and Nursery Care	Covered at the applicable service or place of treatment cost share.	Covered 100% 1	Covered 90% 1

 

 

 

 

 

 

Footnotes:

1. After deductible.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Semi-Private Room, General Nursing Care, Hospital Services and Supplies	Covered 100% 1	Covered 100% 1	Covered 90% 2
Inpatient Consultation	Covered 100%	Covered 100% 2	Covered 90% 2
Chemotherapy	Covered 100% 3	Covered 100% 2	Covered 90% 2

 

 

 

 

 

 

Footnotes:

1. After deductible for unlimited days. Prior authorization may be required.
2. After deductible.
3. For inpatient.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Skilled Nursing Care 1	Covered 100% 2	Covered 100% 3	Covered 90% 3
Hospice Care	Covered under Original Medicare while on the plan.	Covered 100% 4	Covered 90% 4
Home Health Care 5	Covered 100% 6	Covered 100% 7	Covered 90% 7

 

 

 

 

 

 

Footnotes:

1. Must meet medical criteria.
2. Combined in-network and out-of-network benefits limited to 100 days per benefit period. Prior authorization required.
3. After deductible. Combined in-network and out-of-network benefits limited to 100 days per benefit period. Prior authorization required. 
4. After deductible. Prior authorization may be required.
5. Must be medically necessary.
6. Excludes personal hoome care.
7. After deductible. Combined in-network and out-of-network benefit limited to 60 days per calendar year.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Surgery and Related Surgical Services	Covered 96-100%	Covered 100% 1	Covered 90% 2

 

 

 

 

Footnotes:

1. After deductible. Prior authorization may be required.
2. After deductible.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Inpatient Mental Health/ Substance Abuse Care	Covered 100% 1	Covered 100% 2	Covered 90% 3
Outpatient Mental Health/ Substance Abuse Care	Covered 100% 3	Covered 100% 4	Covered 90% 3

 

 

 

 

 

 

Footnotes:

1. 190 day limit in a psychiatric facility. Prior athorization required.
2. After deductible. Prior authorization may be required.
3. After deductible.
4. Prior authorization may be required.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Allergy Testing and Therapy 1	Covered 96% 2	Covered 100% 3	Covered 90% 2
Spinal and Osteopathic Manipulation	Covered 96% 4	$20 Copay 5	Covered 90% 6
Outpatient Diabetes Management Program 7	Covered 100% 8	Covered 100% 8	Covered 90% 2
Outpatient Physical, Speech, and Occupational Therapy	Covered 100% 9	$20 Copay 10	Covered 90% 6
Durable Medical Equipment and Medical Supplies 11	Covered 96-100% 12	Covered 80% 2	Covered 80% 12
Private Duty Nursing	Covered 80% 2	Not covered	Not covered
Autism Spectrum Disorder 13	Covered 96-100% 14	Covered 80% 2	Covered 80% 2

 

 

 

 

 

 

 

 

 

 

Footnotes:

1. Includes allergy injections.
2. After deductible.
3. Office visit copay may apply to consultations.
4. After deductible. No visit limits.
5. Combined in-network and out-of-network benefit limited to 24 visits per calendar year.
6. After deductible. Prior authorization may be required. Limits on the number of visits may apply.
7. Certified providers only.
8. For diabetic training.
9. After deductible. Prior authorization may be required. No visit limit.
10. Combined in-network and out-of-network benefit limited to 60 visits per calendar year. Prior athorization required.
11. Including breastfeeding equipment.
12. After deductible. Prior authorization may be required.
13. Applied behavioral analysis treatment, when rendered by an approved board-certified behavioral analyst. Limited through age 19.
14. After deductible. Limited to Medicare covered services. Prior authorization may be required.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.

Benefit	MSU Medicare Advantage Plan	MSU Non-Medicare Plan
	In-Network and Out-of-Network*	In-Network	Out-of-Network
Foreign Travel 1	Members will be required to pay for services received and submit a claim to Humana for reimbursement along with proof of payment and any medical information or records available from the provider. These charges would be converted to U.S. currency and reimbursed based on the Medicare allowed amount and plan maximums for out of country services.	Emergency care received while traveling outside the U.S. or taking a cruise is covered. Members will be required to pay for services received and submit a claim to Personify Health for reimbursement along with proof of payment and any medical information or records available from the provider. The charges will be converted to U.S. currency and reimbursed to the member under the out-of-network benefits after first applying either the $50 emergency room copayment or the out-ofnetwork deductible of $500 and 10% copay, depending on services received.	Emergency care received while traveling outside the U.S. or taking a cruise is covered. Members will be required to pay for services received and submit a claim to Personify Health for reimbursement along with proof of payment and any medical information or records available from the provider. The charges will be converted to U.S. currency and reimbursed to the member under the out-of-network benefits after first applying either the $50 emergency room copayment or the out-of-network deductible of $500 and 10% copay, depending on services received.

 

 

Footnotes:

1. Individuals living internationally are not eligible for the Humana or Personify Health plans.

* The in-network and out-of-network benefits are structured the same for any member of this plan. Any provider who is eligible to participate in Medicare can treat and receive payment from Humana. Humana pays providers according to the Original Medicare fee schedule less any member plan responsibility. Medicare participating providers may not balance bill members.