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Health Insurance Terms

Unsure what particular health insurance terms mean? The HumanaOne glossary includes both a definition and an example for some common health insurance terms. All examples assume the services are covered by the plan and are provided by in-network providers. If you choose to see an out-of-network provider, your costs will be higher.

If you have additional questions about health insurance or HumanaOne plans, please contact our Health Insurance Advisors.

Health Insurance Term
Definition
HumanaOne Example

Access Fee

A specified dollar amount to be paid by an insured person to a provider toward the covered expenses of certain benefits.

Some HumanaOne plans have access fees for certain services suchas emergency room visits. The access fee is per visit. You are still responsible for any required deductible, coinsurance, and copayments in addition to the access fee. The access fee is waived if you're admitted to the hospital.

 

Annual Maximum

An annual maximum, or cap, is a defined dollar amount Humana will pay toward your covered expenses within a calendar year. You will be responsible for covered healthcare expenses that exceed the selected amount.

There are two ways to lower your monthly premium: raise your annual deductible or keep your annual deductible low and include an annual maximum on the benefits Humana will pay. Annual maximums allow you to have both an affordable premium and low deductible. Only some HumanaOne plans have annual maximums. Others don't.

 

Coinsurance

The portion of covered expenses a covered person must pay in addition to any copayments, access fees, and deductible.

If you have an 80/60 plan, HumanaOne pays 80% coinsurance for some eligible in-network services after you've met your deductible. You pay the remaining 20%, up to your out-of-pocket maximum. Also, you still may be responsible for copays and access fees.

 

Copayment

A specified dollar amount to be paid by an insured person to a provider toward the covered expenses of certain benefits.

If you select the physician copayment option for HumanaOne, you'll have a $35 copayment for each primary care visit and a $60 specialist copayment until you use your plan's allotted in-network visits (if there is an allotment).

 

Deductible

The amount of covered expenses that a covered person must incur in a calendar year and is responsible to pay before we pay certain covered expenses.

HumanaOne offers a wide range of deductibles. By choosing a higher deductible, you can lower your annual premium.

 
 

Effective Date

The date your health insurance coverage begins.

Depending on your state, applicants who haven't had major medical coverage within 63 days of applying may be required to choose an effective date 30 to 45 days after the date of application. Or you may be given two start dates:

  • Coverage for accidents and routine care will start the day you request (subject to approval)
  • Coverage for sickness-related services will begin on the 15th day after your approved effective date

 

Eligible Dependent

A dependent, usually a child, who meets all the requirements to receive health insurance coverage through someone else's plan.

In most states, eligible dependents for HumanaOne plans include children 2 weeks old to a maximum age of 25 years old (unless specified higher by your state).

Requirements may vary for Short Term Medical plans.

 

Health Insurance Portability & Accountability Act (HIPAA)

A 1996 federal law that expanded health insurance coverage for those who lost their jobs or changed jobs. This law also regulated the electronic exchange of healthcare data, including the security of personably identifiable information.

Rest assured that all the information you provide HumanaOne, both online and through the call center, is secure and protected in accordance with HIPAA guidelines.

 

Health Savings Account (HSA)

A Health Savings Account is a medical savings account that gives you a tax-free way to save, budget for, and pay qualified medical expenses. Tax deductibility varies by state; check with your local tax advisor for details.

You must be enrolled in an IRS-qualified High Deductible Health Plan to contribute to a Health Savings Account.

HumanaOne offers several High-Deductible Health Plans which can be combined with a Health Savings Account to save money, tax-free, for medical expenses.

 

Health Plan

A health plan provides insurance protection against illnesses or injury. In addition, some health plans supplement the cost of preventive care such as routine checkups.

HumanaOne is designed for individuals and their families. It includes coverage for inpatient and outpatient hospital and doctor's expenses. Many of our plans include coverage for prescription drugs and preventive care, as well.

 

High-Deductible Health Plan (HDHP)

A High-Deductible Health Plan is a type of insurance that typically consists of a lower premium, higher deductible, and no copayments. All expenses incurred are credited toward the deductible until it is met. Many of these plans can also be combined with a Health Savings Account (HSA).

For many people, a high-deductible health plan combined with an HSA costs less each year because premiums are lower, prescription drug costs count toward the deductible, and the out-of-pocket maximum includes the deductible.

 
 

Issue Age

An applicant's age when submitting a completed application.

The issue age for primary/spouse applicants for HumanaOne plans is 19 years to 64½ years old. Dependent children are eligible under age 26 - dependent ages may vary by state. Requirements may vary for Short Term Medical plans.

 

Lifetime Maximum

A set limit on the total benefits to be paid by the plan over the course of the health insurance policy/certificate.

HumanaOne Short Term plans have a Lifetime Maximum of $2 million in total benefits for covered expenses over the lifetime of the policy. All other HumanaOne plans have an unlimited Lifetime Maximum.

 

Maximum Allowable Fee

Whichever is less of the following:

  • Fee charged by the provider for services;
  • Fee that has been negotiated with the provider (directly or through intermediaries) or shared savings contracts for the services;
  • Fee established by us through rate comparison from regional or national databases or scheduled for the same or similar services from a geographic area determined by us;
  • Fee based on rates negotiates by us or other payors with one or more network providers for the same or similar services from a geographic area determined by us;
  • Fee equal to the provider's costs for providing the same or similar services as reported by such provider in its most recent publicly available Medicare cost report submitted to the Centers for Medicare & Medicaid Services (CMS) annually;
  • Fee based on a percentage determined by us of the fee Medicare allows for the same or similar services provided in the same geographic area.

The bill a covered person receives for services from non-network providers may be significantly higher than the maximum allowable fee. In addition to the out-of-pocket deductible, copayments, access fees, coinsurance, or out-of-pocket limit, a covered person is responsible for the difference between the maximum allowable fee and the amount the provider bills for the services. Any amount the covered person pays to the provider in excess of the maximum allowable fee does not apply to the out-of-pocket limit or deductible.

 

Medicare

Administered by the U.S. federal government, Medicare provides health insurance for those age 65 and older and those with certain disabilities.

Individuals who qualify for Medicare aren't eligible for HumanaOne health insurance for individuals and families.

 
 

Network / Participating Provider

A hospital, healthcare treatment facility, healthcare practitioner, or other provider who is designated as such and has a signed agreement with us, or who has been designated by us to provide services to covered persons.

More than 350,000 doctors are members of Humana's network and provide discounts to Humana health plan members. By using a Network / Participating provider you save more money.

 

Out-of-Pocket Limit

Individual Major Medical (IMM): The portion of coinsurance a covered person pays for certain covered expenses before we begin paying at 100% for some services, less deductibles, copays, and access fees.

High Deductible Health Plan (HDHP): The portion of coinsurance a covered person pays for certain covered expenses before we begin paying at 100% for some services, including deductibles, copays, and access fees.

Let's say you have a $1,000 deductible and $3,000 out-of-pocket limit. Humana pays 80% for most eligible in-network healthcare costs. Once you reach your out-of-pocket limit - in other words, paid your $1,000 deductible AND your $3,000 out-of-pocket limit in coinsurance - Humana pays 100% of most eligible, in-network healthcare costs.

 

Pre-Existing Condition

A health condition for which any of the following occurred before the effective date of your insurance:

  • You had signs or symptoms of the condition
  • You received treatment, advice, tests related to the condition, or prescription drugs were prescribed for the condition
    OR
  • A healthcare professional told you to get tests or treatment for the condition

Unfortunately, not everyone is eligible for HumanaOne health insurance for individuals and families; certain pre-existing conditions may cause your application to be denied. The pre-existing condition limitation does not apply to a covered person who is under the age of 19. View details on Pre-Existing Conditions.

 

Premium

A monthly, quarterly, or semi-annual payment required to secure a health plan. The premium is based on variables like the number of people to insure, health information/history, and the cost of care in your area.

Your initial HumanaOne premium rate is guaranteed for the first 12 months of your plan as long as you maintain your current benefits and rating area.

A Short Term Medical plan does not include a 12-month rate guarantee.

 

Primary Care Physician

Primary Care Physicians are usually the first healthcare provider an insured person contacts for treatment. Physicians considered Primary Care Physicians may vary by state, but they typically include family practitioners, general practitioners, and pediatricians.

Several HumanaOne plans differentiate between Primary Care Physicians and Specialty Care Physicians with regard to the required copayment amount. More information on these differences is available on the plan benefit sheets.

 

Rating Area

This is an area used to determine premium rates, usually by ZIP code. The premium is based on the average healthcare costs, as well as doctor and hospital discounts, in that area.

HumanaOne's premium rates reflect the doctor and hospital discounts in a particular area. This is yet another way Humana's network strength benefits you.

 
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