Humana One – Colorado

Humana One offers quite a few plan choices in Colorado and the highlight is the Portrait plan which is the most popular plan and simplest to understand.  The other plans include the Autograph plan which has some HSA (Health Savings Account) plan options and some higher deductible options which do not include office visit or prescription coverage before the deductible.

They also offer a Monogram plan which is a catastrophic health insurance plan, which has a $7,500 deductible and is for those that need a bare bones medical plan with a very inexpensive premium.

This plan is designed to meet your needs with benefits and features including:

  • • Two deductible options
  • • 80% coverage for most covered in-network medical costs after deductible
  • A prescription drug benefit
  • Coverage for annual exams and physicals
  • A large network you can rely on
  • Unlimited in-network office visits
  • Optional benefits like dental and life coverage at an additional cost

The Portrait Plan comes in either a $1000 deductible or $2500 deductible option and has $2,000 in coinsurance.  The lifetime maximum benefit is 5 million dollars.  There is a $500 name brand drug deductible, but generics are covered with a copay from day 1 of the policy.

This plan is designed to meet your needs with benefits and features including:

  • $7500 deductible
  • 100% coinsurance
  • Drug coverage after the $1,000 brand name deductible
  • $15,000 family deductible
  • Lifetime max is $2 million

Includes:

  • Different deductible choices
  • 6 office visits per year on the copay plan
  • 2 million or 5 million lifetime maximum
  • HSA qualified option
  • Drug coverage option after $1,000 deductible

Humana One Exlusions and Plan Questions in Colorado

Many of the questions that we are commonly asked about the Humana One individual plans can be found below in the exclusions and limitation section.

  • Payments – Network providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to non-network providers are based on maximum allowable fees, as defined in your policy.
  • Non-network providers may balance bill you for charges in excess of the maximum allowable fee.
  • You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or copayment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible.
  • Network primary care and specialist physicians and other providers in Humana’s networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you.

Medical Limitations and Exclusions

This is an outline of the limitations and exclusions for the HumanaOne Individual Health Plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions.

Pre-existing conditions

A pre-existing condition is a sickness, injury or pregnancy for which a covered person incurred charges, received medical treatment, consulted with a healthcare practitioner or took prescription drugs within the 12-month period before their effective date of coverage. Benefits for pre-existing conditions are not payable until the covered person’s coverage has been in force for 12 consecutive months with us. We will waive the pre-existing conditions limitations for those conditions disclosed on the application provided benefits relating to those conditions are not excluded. Conditions specifically excluded by rider are never covered.

Other expenses not covered

Unless stated otherwise no benefits are payable for expenses arising from:

  1. Services not medically necessary or which are experimental, investigational or for research purposes.
  2. Services not authorized or prescribed by a healthcare practitioner or for which no charge is made.
  3. Services while confined in a hospital or other facility owned or operated by the United States government, provided by a person who ordinarily resides in the covered person’s home or who is a family member, or that are performed in association with a service that is not covered under the policy.
  4. Charges in excess of the maximum allowable fee or which exceed any policy benefit maximum.
  5. Expenses incurred before the effective date or after the date coverage terminated.
  6. Cosmetic procedures and any related complications except as stated in the policy.
  7. Custodial or maintenance care.
  8. Any drug, medicine or device which is not FDA approved.
  9. Contraceptives other than oral, including implant systems and devices regardless of the purpose for which prescribed.
  10. Medications, drugs or hormones to stimulate growth.
  11. Legend drugs not recommended or deemed necessary by a healthcare practitioner or drugs prescribed for a non-covered injury or sickness.
  12. Drugs prescribed for intended use other than for indications approved by the FDA or recognized off-label indications through peer-reviewed medical literature; experimental or investigational use drugs.
  13. Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription.
  14. Drugs used in treatment of nail fungus.
  15. Prescription refills exceeding the number specified by the healthcare practitioner or dispensed more than one year from the date of the original order.
  16. Vitamins, dietary products and any other nonprescription supplements.
  17. Infertility services.
  18. Pregnancy and well-baby expenses.
  19. Elective medical or surgical procedures; sterilization, including tubal ligation and vasectomy; reversal of sterilization; abortion; gender change or sexual dysfunction.
  20. Vision therapy; all types of refractive keratoplasties or any other procedures, treatments or devices for refractive correction; eyeglasses; contact lenses; hearing aids; dental exams.
  21. Hearing and eye exams; routine physical examinations for occupation, employment, school, travel, purchase of insurance or premarital tests.
  22. Services received in an emergency room unless required because of emergency care.
  23. Dental services (except for dental injury), appliances or supplies.
  24. War or any act of war, whether declared or not; commission or attempt to commit a civil or criminal battery or felony.
  25. Standby physician or assistant surgeon, unless medically necessary; private duty nursing; communication or travel time; lodging or transportation, except as stated in the policy.
  26. Any treatment for the purpose of reducing obesity, or any use of obesity reduction procedures to treat sickness or injury caused by, complicated by, or exacerbated by obesity, including but not limited to surgical procedures.
  27. Nicotine habit or addiction; educational or vocation therapy, services and schools; light treatment for Seasonal Affective Disorder (S.A.D.); alternative medicine; marital counseling; genetic testing, counseling or services; sleep therapy or services rendered in a premenstrual syndrome clinic or holistic medicine clinic.
  28. Foot care services.
  29. Charges for nonmedical purposes or used for environmental control or enhancement (whether or not prescribed by a healthcare practitioner).
  30. Health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; personal computers and related or similar equipment; communication devices other than due to surgical removal of the larynx or permanent lack of function of the larynx.
  31. Hair prosthesis, hair transplants or implants and wigs.
  32. Temporomandibular joint disorder, craniomaxillary disorder, craniomandibular disorders and any treatment for jaw, joint or head and neck.
  33. Injury or sickness arising out of or in the course of any occupation, employment or activity for compensation, profit or gain, whether or not benefits are available under Workers’ Compensation.This exclusion does not apply to a covered person qualifying as a sole proprietor, officer or partner under state law, and such benefits are not covered under any Workers’ Compensation plan, provided the covered person is not covered under a Workers’ Compensation plan, except for certain professions or activities as stated in the policy.
  34. Inpatient services when in an observation status or when the stay is due to behavioral, social maladjustment, lack of discipline or other antisocial actions not a result of a mental disorder.
  35. Attempted suicide or intentionally self-inflicted injury, while sane.
  36. Charges covered by other medical payments insurance.
  37. Organ transplants not approved based on established criteria or investigational, experimental or for research purposes.
  1. Charges incurred for a hospital stay beginning on a Friday or Saturday unless due to emergency care or surgery is performed on the day admitted.

Optional Dental benefits (with teeth whitening) (15)

You can choose any dentist, but you can save up to 30 percent on out-of-pocket costs when you visit one of the more than 75,000 dentist locations in the PPO network. You can find a dentist by visiting Humana.com.

  • Preventive services plan pays 100% no deductible
  • Oral examinations
  • Routine cleanings
  • X-rays
  • Sealants
  • Topical fluoride treatment
  • Basic services plan pays 50% after deductible
  • Emergency exams and palliative care for pain relief
  • Thumb sucking and harmful habit appliances
  • Space maintainers
  • Amalgam, composite fillings
  • Oral surgery
  • Extractions (routine)
  • Non-cast stainless steel crowns
  • Partial or complete denture repairs/adjustments
  • Teeth whitening services plan pays 50% after deductible
  • $200 lifetime maximum Major services plan pays 50% after deductible
  • Endodontics (root canals)
  • Partial or complete dentures
  • Denture relines/rebases
  • Removable or fixed bridgework • Periodontics • Crowns • Inlays and onlays
  • Orthodontia discount

Members can receive up to 20 percent discount if they visit an orthodontist from the HumanaDental PPO Network and ask for the discount.

Annual Deductible

  • $50 individual
  • $150 family

Annual maximum benefit

• $1,000

To be covered, expenses must be medically necessary and specified as covered. Please see your policy for more information on medical necessity and other specific plan benefits

Dental Limitations and Exclusions

This is an outline of the limitations and exclusions for the HumanaOne Individual Dental Plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions.

Unless stated otherwise, no benefits are payable for expenses arising from:

  1. The course of any occupation or employment for compensation, profit or gain, for which benefits are provided or payable under any Workers’ Compensation or Occupational Disease Act or Law; or where such coverage was available, regardless of whether the coverage was actually applied for.
  2. Services and supplies for which no charge is made, or for which the covered person would not be required to pay in the absence of insurance.
  3. Services furnished by or payable under any plan or law through any Government or any political subdivision.
  4. Services furnished by any hospital or institution owned or operated by the United States Government, unless legally required to pay.
  5. War or any act of war, whether declared or not; or any act of international armed conflict or any conflict involving armed forces of any international authority.
  6. Completion of forms or failure to keep an appointment with a dentist.
  7. Cosmetic dentistry, except as stated in the policy.
  8. Any service related to altering vertical dimension; restoration or maintenance of occlusion; splinting teeth; replacing tooth structures lost as a result of abrasion, attrition or erosion; or bite registration or bite analysis.
  9. Bone grafts, regeneration, augmentation or preservative procedures in edentulous sites.
  10. Implants, including any crowns or prosthetic device attached to it; precision or semi-precision attachments; overdentures and any endodontic treatment associated with it; or other customized attachments.
  11. Infection control.
  12. Fees for treatment by other than a dentist, except as stated in the policy.
  13. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
  14. Prescription drugs or pre-medications, whether dispensed or prescribed.
  15. Any service not listed as a covered expense.
  16. Any service not considered a dental necessity, does not offer a favorable prognosis, does not have uniform professional endorsement, or is experimental or investigational in nature.
  17. Expenses incurred prior to the effective date or after the date coverage is terminated, except for any extension of benefits.
  18. Services provided by a person who ordinarily resides in the covered person’s home or who is a family member.
  19. Charges in excess of the reimbursement limit for the service or supply.
  20. Treatment as a result of an intentionally self-inflicted injury or bodily illness, while sane or insane.
  21. Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans, occlusal adjustments, or tissue preparation associated with impression or placement of a restoration, charged as a separate service.
  22. Repair and replacement of orthodontic appliances.

2 Optional benefits can vary by state and/or plan, and are available at an additional cost.

This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, terms and conditions of the policy will govern. All applications are subject to approval. Waiting periods, limitations and exclusions apply.