Humana is one of East Coast Health Insurance’s top carriers. We have a great relationship with them and their underwriting is one of the most lenient or allowing in the nation. In this article, we will review the standard limitations of a Humana individual plan as well as discuss plan highlights.

Who can apply for Humana’s individual health plan – People between the ages of two weeks and sixty four and a half years of age can apply for HumanaOne health plans. A dependent  child must be less than 31 years of age to apply.

Date the plan starts – If you’ve  had major medical coverage in the last 63 days, your start date can be as early as the day you apply. If you haven’t had coverage in the last 63 days, you’ll have two start dates:

1. Subject to approval, your plan starts on the day you request, with coverage for preventive care and injuries caused by an accident

2. Unless Humana agrees to an earlier date, your start date for sickness begins on the 15th day after the approved effective date of your plan.

Choose your medical deductible – The amount  of covered expenses  you’ll pay out of your pocket before your plan begins to pay its share

Important to know:

  • Deductibles start over each new calendar year
  • Once three family members meet their individual deductibles, the family deductible  will be met for all other family members
  • For families with two people, only two individual deductibles need to be met
  • This plan may include a separate deductible for certain conditions; see the deductible information on page 4 for details
  • The medical deductible  is separate from other deductibles; expenses applied to the medical deductible won’t apply to mental health, prescription drugs, or condition-specific deductibles

Condition-specific deductibles (deductibles for certain  illnesses)

Humana’s plans may include condition-specific deductibles, or CSDs, of $2,500, $5,000, or $7,500 in-network ($5,000, $10,000, or $15,000 out-of-network). CSDs allow you to get coverage for services that wouldn’t be covered otherwise or would have a waiting period. The CSD applies  to certain conditions  listed in your Certificate. If you have any of these  conditions  before your coverage starts, you’ll have coverage  for these services – you just need to meet the separate  deductible first. After you meet the CSD, your plan  will pay for covered expenses  related to the condition at 100% for the rest of the calendar year. Prescriptions used to treat the condition don’t apply to the CSD.

 Network agreements

Network providers agree to accept an agreed-upon amount as payment in full. Network providers aren’t the agents, employees, or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana doesn’t provide medical services. Humana doesn’t endorse or control your healthcare  providers’ clinical judgment or treatment recommendations. Your Certificate  explains  your share  of the cost for network and out-of-network  providers. It may include a deductible, a set amount (copayment or access fee), and a percent of the cost coinsurance).

Pre-Existing Conditions

A pre-existing  condition  is a sickness or bodily injury for which, during the five-year period immediately prior to the covered person’s effective date of coverage:

  1. the covered person sought, received or was recommended medical advice, consultation, diagnosis, care or treatment;
  2. prescription drugs were prescribed;
  3. signs or symptoms were exhibited; or
  4. diagnosis was possible.

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 enrollment form provided benefits relating to those conditions are not excluded. Conditions specifically excluded by rider are never covered. The pre-existing condition limitation does not apply to a covered person who is under the age of 19.

Limitations and  exclusions (things that  are not  covered)

This is an outline of the limitations and exclusions for the HumanaOne health plan listed above. It is designed for convenient reference. Consult the Certificate for a complete list of limitations and exclusions.

Your Certificate  is guaranteed renewable as long as premiums are paid. Other termination provisions apply as listed in the Certificate. Unless specifically stated  otherwise, no benefits will be provided for, or on account of, the following items:

Service and billing exclusions

  • For residents in the EPO service area: Services provided  by a non-network hospital located in EPO service area, except for emergency care, if a network hospital is not reasonably available.
  • Services incurred before the effective date, after the termination date, or when premium is past due, except as expressly provided in the Certificate
  • Services not medically necessary, except for routine preventive services as stated in the Certificate
  • Charges in excess of the maximum allowable fee
  • Charges in excess of the lifetime maximum benefit or any other benefit maximum
  • Services not authorized, furnished or prescribed by a healthcare provider
  • Services for which no charge is made
  • Services provided by a family member or person who resides with the covered person
  • Services rendered by a standby physician, surgical assistant, assistant surgeon, physician assistant, nurse or certified operating room technician unless medically necessary
  • Experimental, investigational, or research services
  • Services that are experimental, investigational, or for research purposes
  • Elective and cosmetic services
  • Cosmetic services, or any related complication
  • Elective medical or surgical procedures
  • Hair prosthesis, hair transplants, or hair implants
  • Prophylactic services
  • Immunizations
  • Immunizations – except as stated in the Certificate
  • Dental, foot care, hearing, and vision services
  • Dental services (except for dental  injury), appliances, or supplies
  • Foot care services
  • Hearing care that is routine
  • Vision examinations or testing, eyeglasses or contact lenses
  • Pregnancy and sexuality services
  • Pregnancy except for complications of pregnancy as defined in the Certificate
  • Lactation therapy
  • Elective medical or surgical abortion  except as stated in
  • Immunotherapy for recurrent abortion
  • Home uterine activity monitoring
  • Sterilization, including tubal ligation and vasectomy
  • Reversal of sterilization
  • Infertility services
  • Sexual dysfunction
  • Sex change services
  • Services rendered in a premenstrual  syndrome clinic
  •  Obesity-related services
  • Any treatment for obesity
  • Surgical procedures for the removal of excess skin and/or fat due to weight loss
  • Illness/injury circumstances
  • Services or supplies provided in connection with a sickness or bodily injury arising out of, or sustained  in the course of, any occupation, employment or activity for compensation,  profit or gain, whether or not benefits are available under Workers’ Compensation except as stated in the Certificate
  • Sickness or bodily injury as a result of war, armed conflict, participation in a riot, influence of an illegal substance, being intoxicated or engaging in an illegal occupation
  • Care in certain settings
  • Private duty nursing
  • Custodial or maintenance care
  • Care furnished while confined in a hospital or institution owned or operated by the United States government or any of its agencies for any service-connected  sickness or bodily injury
  • Certain hospital services
  • Services received in an emergency room unless required because of emergency care
  • Charges for a hospital stay that begins on a Friday or Saturday unless due to emergency care or surgery is performed on the day admitted observation status or when the stay is due to behavioral, social maladjustment, lack of discipline or other antisocial actions which are not the result of mental health
  • Certain mental health services
  • Court-ordered mental health services
  • Services and supplies that are rendered in connection withmental illnesses not classified in the International Classification of Diseases of the U.S. Department of Health and Human Services
  • Services and supplies that are extended beyond the period necessary for evaluation and diagnosis of learning and behavioral disabilities or for mental retardation
  • Marriage counseling
  • Other payment available
  • Services furnished by or payable under any plan or law through a government or any political subdivision, unless prohibited by law
  • Charges for which any other insurance providing medical payments exists
  • Services not considered medical
  • Charges for non-medical items that are used for environmental control or enhancement whether or not prescribed by a healthcare practitioner
  • Alternative medicine
  • Charges for alternative medicine including acupuncture and naturopathic medicine
  • Other
  • Any expense  incurred for services received outside  of the United States while residing outside of the United States for more than six consecutive months in a year except as required by law for emergency care services
  • Services for care or treatment  of non-covered procedures or any related complication
  • Biliary lithotripsy
  • Charges for growth hormones
  • Chemonucleolysis
  • Cranial banding, unless otherwise determined by us
  • Educational or vocational training or therapy, services, and schools
  • Expense for employment, school, sports or camp physical examinations or for the purpose of obtaining insurance, premarital tests/examinations
  • Genetic testing, counseling, or services
  • Hyperhydrosis surgery
  • Immunotherapy for food allergy
  • Light treatment for Seasonal Affective Disorder (S.A.D.)
  • Living expenses; travel; transportation, except as expressly provided in the Certificate
  • Prolotherapy
  • Sensory integration therapy
  • Sleep therapy
  • Treatment for TMJ, CMJ or any jaw joint problem except  as expressly provided in the Certificate
  • Treatment of nicotine habit or addiction
  • Any drug, medicine or device which is not FDA approved
  • Contraceptives
  • Medications, drugs or hormones to stimulate growth
  • Legend drugs not recommended or deemed necessary by a healthcare practitioner or drugs prescribed for a non-covered injury or sickness
  • 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
  • Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription
  • Drugs used in treatment of nail fungus
  • Prescription refills exceeding the number specified by the healthcare practitioner or dispensed more than one year from the date of the original order
  • Vitamins, dietary products and any other nonprescription supplements
  • Certain services and prescription drugs require preauthorization and notification/prior authorization before services are rendered.

Important information about Association plans

The Association, Peoples’ Benefit Alliance, is a membership organization that provides educational information and discounts on goods and services to its members. Membership in the Peoples’ Benefit Alliance is required, at an additional cost, in order to be eligible to apply for this health plan.

This document contains a general summary of covered benefits, exclusions and limitations. Please refer to the Certificate for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms and conditions of the Certificate  will govern.

Your premium  won’t  go up during the first year the Certificate is in force, as long as you stay in the same area and keep the same benefits. After the first year, we have the right to raise premiums on your renewal date, or more frequently if you move out of the service area or change benefits.