Download Humana Booklet PDF

TitleHumana Booklet
LanguageEnglish
File Size7.5 MB
Total Pages51
Table of Contents
                            2097:
	SBC_Non2017
		1: SBC_Non2017
		2: SBC_Flow_Pagex
		3: SBC_Flow_Pagex
		4: SBC_Flow_Pagex
		5: SBC_Flow_Pagex
		6: SBC_Flow_Pagex
		7: SBC_Flow_Pagex
		8: SBC_CoverageSampleNon2017
		9: SBC_Questions_Non2017
	Multi-Language Interpreter Services
		10: pg_Multi-Language Interpreter Services_pg1
		11: pg_Multi-Language Interpreter Services_pg2
	2115:
		SBC_Non2017
			1: SBC_Non2017
			2: SBC_Flow_Pagex
			3: SBC_Flow_Pagex
			4: SBC_Flow_Pagex
			5: SBC_Flow_Pagex
			6: SBC_Flow_Pagex
			7: SBC_CoverageSampleNon2017
			8: SBC_Questions_Non2017
		Multi-Language Interpreter Services
			9: pg_Multi-Language Interpreter Services_pg1
			10: pg_Multi-Language Interpreter Services_pg2
	2082:
		SBC_Non2017
			1: SBC_Non2017
			2: SBC_Flow_Pagex
			3: SBC_Flow_Pagex
			4: SBC_Flow_Pagex
			5: SBC_Flow_Pagex
			6: SBC_Flow_Pagex
			7: SBC_CoverageSampleNon2017
			8: SBC_Questions_Non2017
		Multi-Language Interpreter Services
			9: pg_Multi-Language Interpreter Services_pg1
			10: pg_Multi-Language Interpreter Services_pg2
	GCHHR2ZEN_6943BW_Ltr1
	Get Started Flyer 08750_GCHJLV8EN unl
	Get to Silver Flyer 08750_GCHJLU3EN unl
	Telemedicine MEMBER flyer
	Preventative services
	My Humana Mobile Flyer App
	Humana Pharmacy Flyer
	EyeMed
	Register My Humana
	Privacy Notice
                        
Document Text Contents
Page 1

Questions: Call www.humana.com or by calling 1-866-4ASSIST (427-7478) or visit us at www.humana.com

If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view

the Glossary at www.dol.gov/ebsa/healthreform or call www.humana.com or by calling 1-866-4ASSIST (427-7478) to request

a copy. 1 of 11

SBC0125W101720161441TXEF0017

HUMANA HEALTH PLAN OF TX, INC/HUMANA INSURANCE

CO: TX LG NPOS 14 Coverage Period: Beginning on or after 01/01/2017

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage For: Individual + Family | Plan Type: NPOS

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or

plan document at www.humana.com or by calling www.humana.com or by calling 1-866-4ASSIST (427-7478) .

Important Questions Answers Why this Matters:

What is the overall

deductible?

Network:

$0 Individual / $0 Family

Non-Network:

$5,000 Individual / $10,000 Family

Doesn't apply to prescription drugs and

network preventive services.

Co-insurance and co-payments don't

count toward the deductible

You must pay all the costs up to the deductible amount before this plan begins to

pay for covered services you use. Check your policy or plan document to see

when the deductible starts over (usually, but not always, January 1st). See the

meet the deductible.

chart starting on page 2 for how much you pay for covered services after you

Are there other

deductibles for specific

services?

No. You don't have to meet deductibles for specific services, but see the chart

starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket

limit on my expenses

Yes. For Network providers

$6,250 Individual / $12,500 Family

For Non-Network providers

$15,000 Individual / $30,000 Family

The out-of-pocket limit is the most you could pay during a coverage period

(usually one year) for your share of the cost of covered services. This limit helps

you plan for health care expenses.

What is not included in

the out-of-pocket limit?

Premiums, Balance-billed charges, Health

care this plan doesn't cover, Penalties,

Non-network transplant, non-network

prescription drugs, non-network specialty

drugs

Even though you pay these expenses, they don't count toward the out-of-pocket

limit.

Is there an overall annual

limit on what the plan

pays?

No.

specific covered services, such as office visits.

The chart starting on page 2 describes any limits on what the plan will pay for

Does this plan use a

network of providers?

Yes. See www.humana.com or call

1-866-4ASSIST (427-7478) for a list of

Network providers.

If you use an in-network doctor or other health care provider, this plan will pay

some or all of the costs of covered services. Be aware, your in-network doctor or

hospital may use an out-of-network provider for some services. Plans use the

term in-network, preferred, or participating for providers in their network. See

the chart starting on page 2 for how this plan pays different kinds of providers.

Page 2

2 of 11

Do I need a referral to

see a specialist?

No. You can see the specialist you choose without permission from this plan.

Are there services this

plan doesn't cover?

Yes.

or plan document for additional information about excluded services .

Some of the services this plan doesn't cover are listed on page 6. See your policy

• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the

plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you

haven't met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the

allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the

allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing .)

• This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common

Medical Event
Services You May Need

Your Cost If

You Use a

Network

Provider

Your Cost if

You Use a

Non-Network

Provider

Limitations & Exceptions

If you visit a health

care provider's office

or clinic

Primary care visit to treat an

injury or illness

$25 copay/visit 50% coinsurance -------------------none-------------------

Specialist visit $65.00

copay/visit

50% coinsurance -------------------none-------------------

Other practitioner office visit Chiropractor

Exam:

$65 copay/visit

Chiropractor

Exam:

50% coinsurance

-------------------none-------------------

Preventive care / screening /

immunization

No charge 50% coinsurance -------------------none-------------------

If you have a test Diagnostic test (x-ray, blood

work)

No charge 50% coinsurance Cost share may vary based on where service is performed

Imaging (CT/PET scans,

MRIs)

$375 copay 50% coinsurance Cost share may vary based on where service is performed

Preauthorization may be required - if not obtained,

penalty will be 50%

Page 25

4 of 10

Common

Medical Event
Services You May Need

Your Cost If

You Use a

Network

Provider

Your Cost if

You Use a

Non-Network

Provider

Limitations & Exceptions

Specialty drugs 35% coinsurance 50% coinsurance 25% coinsurance when filled via a preferred network

specialty pharmacy

Preauthorization may be required - if not obtained,

penalty will be 100% for certain prescription drugs

If you have

outpatient surgery

Facility fee (e.g., ambulatory

surgery center)

No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

Physician/surgeon fees No charge after

deductible

30% coinsurance -------------------none-------------------

If you need

immediate medical

attention

Emergency room services $150 copay/visit $150 copay/visit Copayment waived if admitted

Emergency medical

transportation

No charge after

deductible

No charge after

deductible

-------------------none-------------------

Urgent care $75 copay/visit 30% coinsurance -------------------none-------------------

If you have a hospital

stay

Facility fee (e.g., hospital room) No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

Physician/surgeon fee No charge after

deductible

30% coinsurance -------------------none-------------------

If you have mental

health, behavioral

health, or substance

abuse needs

Mental/Behavioral health

outpatient services

$25 copay/visit 30% coinsurance -------------------none-------------------

Mental/Behavioral health

inpatient services

No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

Substance use disorder

outpatient services

$25 copay/visit 30% coinsurance -------------------none-------------------

Substance use disorder

inpatient services

No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

If you are pregnant Prenatal and postnatal care No charge after

deductible

30% coinsurance -------------------none-------------------

Delivery and all inpatient

services

No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

If you need help

recovering or have

other special health

needs

Home health care No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50%

Rehabilitation services $40 copay/visit 30% coinsurance Therapies:

Page 26

5 of 10

Common

Medical Event
Services You May Need

Your Cost If

You Use a

Network

Provider

Your Cost if

You Use a

Non-Network

Provider

Limitations & Exceptions

Preauthorization may be required - if not obtained,

penalty will be 50%

Manipulations and Therapies:

60 Physical Therapy, Occupational Therapy, Speech

Therapy, Cognitive Therapy, Audiology Therapy visit

limit per year includes manipulations & adjustments

For non-network, 10 Physical Therapy, Occupational

Therapy, Cognitive Therapy, Speech Therapy, Audiology

Therapy visits per year includes manipulations &

adjustments

Habilitation services $40 copay/visit 30% coinsurance

Skilled nursing care No charge after

deductible

30% coinsurance 60 day limit per cal yr/plan yr

Preauthorization may be required - if not obtained,

penalty will be 50%

Durable medical equipment No charge after

deductible

30% coinsurance Preauthorization may be required - if not obtained,

penalty will be 50% for durable medical equipment $750

and over

Excludes vehicle and home modifications,exercise and

bathroom equipment

Hospice service No charge after

deductible

30% coinsurance -------------------none-------------------

If your child needs

dental or eye care

Eye exam Not Covered Not Covered -------------------none-------------------

Glasses Not Covered Not Covered -------------------none-------------------

Dental check-up Not Covered Not Covered -------------------none-------------------

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other

excluded services.)

• Acupuncture, unless it is prescribed by a

physician for rehabilitation purposes

• Cosmetic surgery, unless to correct a

functional impairment

• Private-duty nursing

• Bariatric surgery • Dental care (Adult), unless for dental injury

of a sound natural tooth

• Routine eye care (Adult)

• Child dental check-up • Infertility treatment • Routine foot care

• Child eye exam • Long-term care • Weight loss programs

Page 50

GN14474HH 713 Page 3 of 4

• E-mailing us at [email protected]
Send completed request form to:
Humana Inc.
Privacy Office 003/10911
101 E. Main Street
Louisville, KY 40202

What should I do if I believe my privacy has
been violated?
If you believe your privacy has been violated in any way,
you may file a complaint with us by calling us at
1-866-861-2762 any time.

You may also submit a written complaint to the
U.S. Department of Health and Human Services,
Office of Civil Rights (OCR). We will give you the appropriate
OCR regional address on request. You also have the option
to e-mail your complaint to [email protected] We
support your right to protect the privacy of your personal
and health information. We will not retaliate in any way
if you elect to file a complaint with us or with the U.S.
Department of Health and Human Services.

What will happen if my private information is used or
disclosed inappropriately?
You have a right to receive a notice that a breach has
resulted in your unsecured private information being
inappropriately used or disclosed. We will notify you in a
timely manner if such a breach occurs.

PRIVACY NOTICE CONCERNING FINANCIAL
INFORMATION
We and our affiliates understand that the privacy of your
personal information is important to you. We take your
privacy seriously and your trust in our ability to protect
your private information is very important to us. This
notice describes our policy regarding the confidentiality
and disclosure of personal financial information.

How do we collect information about you?
We collect information about you and your family when
you complete applications and forms. We also collect
information from your dealings with us, our affiliates, or
others. For example, we may receive information about
you from participants in the healthcare system, such
as your doctor or hospital, as well as from employers
or plan administrators, credit bureaus, and the Medical
Information Bureau.

What information do we receive about you?
The information we receive may include such items as
your name, address, telephone number, date of birth,
Social Security number, premium payment history, and
your activity on our Website. This also includes information
regarding your medical benefit plan, your health benefits,
and health risk assessments.

Where will we disclose your information?
We may share your information with affiliated companies
and non-affiliated third parties, as permitted by
law. We may also provide your information to other
financial institutions with which we have joint marketing
agreements in order to provide you with offers for
products and services you may find of value or which are
health-related.

What can I prevent with an opt-out disclosure?
You can prevent the disclosures to non-affiliated third
parties that provide products and services not
offered by us or where the non-affiliated company
provides services related to your plan by requesting to
opt-out of such disclosures. Your opt-out request will
apply to all members or individuals covered under your
identification number or member account.

Your opt-out request will continue to apply until you revoke
your request or terminate your membership.

How do I request an opt-out?
At any time you can tell us not to share any of your
personal information with affiliated companies that
provide offers other than our products or services. If
you wish to exercise your opt-out option, or to revoke a
previous opt out request, you need to provide the following
information to process your request: your name, date of
birth, and your member identification number. You can use
any of the methods below to request or revoke your opt-
out:
• Call us at 1-866-861-2762
• E-mail us at [email protected]
• Send your opt-out request to us in writing:
Humana Inc.

Privacy Office 003/10911
101 E. Main Street
Louisville, KY 40202

We follow all federal and state laws, rules, and regulations
addressing the protection of personal and health
information. In situations when federal and state laws,

Notice of Privacy Practices
(continued)

Page 51

GN14474HH 713 Page 4 of 4

rules, and regulations conflict, we follow the law, rule, or
regulation which provides greater protection.

The following affiliates and subsidiaries also adhere to our
privacy policies and procedures:

American Dental Plan of North Carolina, Inc.
American Dental Providers of Arkansas, Inc.
Arcadian Health Plan, Inc.
CarePlus Health Plans, Inc.
Cariten Health Plan, Inc.
Cariten Insurance Company
CHA HMO, Inc.
CompBenefits Company
CompBenefits Dental, Inc.
CompBenefits Insurance Company
CompBenefits of Alabama, Inc.
CompBenefits of Georgia, Inc.
CorpHealth, Inc. dba LifeSynch
CorpHealth Provider Link, Inc.
DentiCare, Inc.
Emphesys, Inc.
Emphesys Insurance Company
HumanaDental Insurance Company
Humana AdvantageCare Plan, Inc. fna Metcare Health
Plans, Inc.
Humana Benefit Plan of Illinois, Inc. fna OSF Health Plans,
Inc.
Humana Employers Health Plan of Georgia, Inc.
Humana Health Benefit Plan of Louisiana, Inc.

Humana Health Company of New York, Inc.
Humana Health Insurance Company of Florida, Inc.
Humana Health Plan of California, Inc.
Humana Health Plan of Ohio, Inc.
Humana Health Plan of Texas, Inc.
Humana Health Plan, Inc.
Humana Health Plans of Puerto Rico, Inc.
Humana Insurance Company
Humana Insurance Company of Kentucky
Humana Insurance Company of New York
Humana Insurance of Puerto Rico, Inc.
Humana MarketPOINT, Inc.
Humana MarketPOINT of Puerto Rico, Inc.
Humana Medical Plan, Inc.
Humana Medical Plan of Michigan, Inc.
Humana Medical Plan of Pennsylvania, Inc.
Humana Medical Plan of Utah, Inc.
Humana Pharmacy, Inc.
Humana Regional Health Plan, Inc.
Humana Wisconsin Health Organization Insurance
Corporation
Kanawha Insurance Company*
Managed Care Indemnity, Inc.
Preferred Health Partnership, Inc.*
Preferred Health Partnership of Tennessee, Inc.
The Dental Concern, Inc.
The Dental Concern, Ltd.

* These affiliates and subsidiaries are only covered by the
Privacy Notice Concerning Financial Information section.

Notice of Privacy Practices
(continued)

Similer Documents