Humana One offers 3 main plan types in Michigan including the Portrait, Autograph, and Monogram plans. The Portrait plan is the best of the 3 plans from Humana and offers office visit copays and prescription copays before the deductible and comes either as a $1,000 or $2,500 deductible.
The Humana One Monogram plan comes in only one variation which is a $7,500 deductible and covers 100% of all medical expenses (besides prescription) after that deductible. Of course it is so high that it doesn’t really matter, but the plan is a good choice as a catastrophic plan as it will cover office visits after the deductible and doesn’t just cover hospitalization like most other catastrophic plans.
The Autograph plan has like ten choices including both HSA and non HSA so it requires more explanation then I can cover here.
Humana One Plan Details – Michigan
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.
1. When you obtain care from non-network providers:
- 50 percent of your payment toward the deductible is credited to the deductible for network providers
- 50 percent of your out-of-pocket costs are credited to the out-of-pocket maximum for network providers
Once you meet your deductible and out-of-pocket expense limits, the plan pays 100 percent for covered services.
2. Benefit payable after 90-day waiting period for preventive care and 12-month waiting period for mental health.
3. Benefit maximum for preventive care is limited to $300 per person per calendar year, subject to applicable coinsurance.
4. MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies are subject to applicable coinsurance after deductible.
5. Outpatient benefits payable after 90-day waiting period for nonemergency removal of tonsils and/or adenoids, and after 180-day waiting period for nonemergency surgical treatment for bunions, varicose veins, hemorrhoids or hernia (does not apply to strangulated or incarcerated hernia).
6. If a non-network pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement. The covered person will also be responsible for 30% of the actual charge made by the dispensing pharmacy, after the applicable copayment.
7. Counseling for the hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
Optional benefits
These are available to add for an additional cost
• medical out-of-pocket maximum does not apply to drug coverage
• prescription drug deductible
• lifetime maximum
• supplemental accident benefit ($500 or $1,000)
(treatment must be provided within 90 days of the injury)
With this option no deductible is required before Rx benefits are payable
Increase to $8,000,000 per covered person
First $500 per accident at 100%, then base plan benefits apply or
First $1,000 per accident at 100%, then base plan benefits apply
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 Humana One individual health plan listed above. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. Your policy is guaranteed renewable as long as premiums are paid. Other termination provisions apply as listed in the policy.
Eligibility – The issue ages for Humana One individual health plans are two months to 64.5 years. The maximum age for a dependent child is 25 years if the child is a full-time student and 19 years if the child is not a full-time student.
Pre-existing conditions - A pre-existing condition is a sickness or injury which was diagnosed or treated, or which produced signs or symptoms that would cause an ordinarily prudent person to seek treatment, during the six-month period before the covered person’s 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 limitation 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 Non Covered Expenses
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. Infertility services.
9. Pregnancy and well-baby expenses.
10. Elective medical or surgical procedures; sterilization, including tubal ligation and vasectomy; reversal of sterilization; abortion; gender change or sexual dysfunction.
11. Vision therapy; all types of refractive keratoplasties or any other procedures, treatments or devices for refractive correction; eyeglasses; contact lenses; hearing aids; dental exams.
12. Hearing and eye exams; routine physical examinations for occupation, employment, school, travel, purchase of insurance or premarital tests.
13. Services received in an emergency room unless required because of emergency care.
14. Dental services (except for dental injury), appliances or supplies.
15. War or any act of war, whether declared or not; commission or attempt to commit a civil orcriminal battery or felony.
16. Standby physician or assistant surgeon, unless medically necessary; private duty nursing; communication or travel time; lodging or transportation, except as stated in the policy.
17. 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.
18. 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.
19. Foot care services, except as stated in the policy.
20. Charges for nonmedical purposes or used for environmental control or enhancement (whether or not prescribed by a healthcare practitioner).
21. 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.
22. Hair prosthesis, hair transplants or implants and wigs.
23. Temporomandibular joint disorder, craniomaxillary disorder, craniomandibular disorders and any treatment for jaw, joint or head and neck neuromuscular disorders.
24. 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.
25. Attempted suicide or intentionally self-inflicted injury, whether sane or insane.
26. Charges covered by other medical payments insurance.
27. Organ transplants not approved based on established criteria or investigational, experimental or for research purposes.
28. 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.
29. Any drug, medicine or device which is not FDA approved.
30. Contraceptives other than oral, including implant systems and devices regardless of the purpose for which prescribed.
31. Medications, drugs or hormones to stimulate growth.
32. Legend drugs not recommended or deemed necessary by a healthcare practitioner or drugs prescribed for a noncovered injury or sickness.
33. 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.
34. Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription.
35. Drugs used in treatment of nail fungus.
36. Prescription refills exceeding the number specified by the healthcare practitioner or dispensed more than one year from the date of the original order.
37. Vitamins, dietary products and any other nonprescription supplements.
38. 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.
39. Any drug, medicine or device which is not FDA approved.
40. Contraceptives other than oral, including implant systems and devices regardless of the purpose for which prescribed.
41. Medications, drugs or hormones to stimulate growth.
42. Legend drugs not recommended or deemed necessary by a healthcare practitioner or drugs prescribed for a noncovered injury or sickness.
43. 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.
44. Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription.
45. Drugs used in treatment of nail fungus.
46. Prescription refills exceeding the number specified by the healthcare practitioner or dispensed more than one year from the date of the original order.
47. Vitamins, dietary products and any other nonprescription supplements.
48. 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.
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.
