Health Insurance Glossary

TERM DEFINITION HumanaOne EXAMPLE

Health Plan A health plan provides insurance protection against illnesses or injuries, and supplements 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 physician expenses, prescription drugs, preventive care and more.

Premium A monthly, quarterly or semi-annual payment required to secure a health plan. Premium is based on variables like the number of people to insure, health information/history and the cost of care in your rating area. Your HumanaOne premium rate is guaranteed for the first 12 months of your plan as long as you maintain your current benefits and rating area.

Deductible The amount of covered expense that a covered person must incur in a calendar year and is responsible to pay before we pay certain benefits. If you have a 80/60 plan, HumanaOne offers deductibles ranging from $500 to $5,000. By choosing a higher deductible, you can lower your annual premium.

Coinsurance The portion of covered expenses a covered person must pay in addition to any copayments and deductible. If you have a 80/60 plan, HumanaOne pays 80% coinsurance for eligible in-network services after you’ve met your deductible. You pay the remaining 20%, up to your out-of-pocket maximum.

Copayment A specified dollar amount to be paid by a covered person to a provider toward covered expenses of certain benefits. If you select the physician copayment option for HumanaOne, you’ll have a $25 copayment for each primary care visit and a $40 specialist copayment to total four in-network visits.

Out-of-Pocket Limit Individual Major Medical (IMM): The portion of coinsurance a covered person pays for certain services before we begin paying at 100%, less deductibles and copays.
High Deductible Health Plan (HDHP): The portion of coinsurance a covered person pays for certain services before we begin paying at 100%, including deductibles and copays. Let’s say you have a $1,000 deductible and $3,000 OOPM. Humana pays 80% of eligible
in-network health care costs. Once you reach your OOPM (paid your $1,000 deductible AND your $3,000 out-of-pocket limit in coinsurance). Humana pays 100% of eligible, in-network health care costs.

Network Provider A hospital, health care treatment facility, health care 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 336,000 doctors are members of Humana’s network and provide discounts to Humana health plan members.

Rating Area This is an area used for determining premium rates, usually by ZIP Code. The premium is based on the average health care costs and physician/hospital discounts in that area. HumanaOne’s premium rates reflect the physician and hospital discounts in a particular area. This is yet another way Humana’s network strength benefits you.

Maximum Allowable Fee The lesser of:

The fee charged by the provider for the services;

The fee that has been negotiated with the provider whether directly or through one or more intermediaries, or shared savings contracts for the services;

The fee established by us by comparing rates from one or more regional or national databases or schedules for the same or similar services from a geographic area determined by us;

The fee based on rates negotiated by us or other payors with one or more network providers in a geographic area determined by us for the same or similar services;

The 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 and Medicaid Services (CMS) annually; or

The 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, 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 will not apply to the out-of-pocket limit or deductible.

TERM	DEFINITION	HumanaOne EXAMPLE
Health Plan	A health plan provides insurance protection against illnesses or injuries, and supplements 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 physician expenses, prescription drugs, preventive care and more.
Premium	A monthly, quarterly or semi-annual payment required to secure a health plan. Premium is based on variables like the number of people to insure, health information/history and the cost of care in your rating area.	Your HumanaOne premium rate is guaranteed for the first 12 months of your plan as long as you maintain your current benefits and rating area.
Deductible	The amount of covered expense that a covered person must incur in a calendar year and is responsible to pay before we pay certain benefits.	If you have a 80/60 plan, HumanaOne offers deductibles ranging from $500 to $5,000. By choosing a higher deductible, you can lower your annual premium.
Coinsurance	The portion of covered expenses a covered person must pay in addition to any copayments and deductible.	If you have a 80/60 plan, HumanaOne pays 80% coinsurance for eligible in-network services after you’ve met your deductible. You pay the remaining 20%, up to your out-of-pocket maximum.
Copayment	A specified dollar amount to be paid by a covered person to a provider toward covered expenses of certain benefits.	If you select the physician copayment option for HumanaOne, you’ll have a $25 copayment for each primary care visit and a $40 specialist copayment to total four in-network visits.
Out-of-Pocket Limit	Individual Major Medical (IMM): The portion of coinsurance a covered person pays for certain services before we begin paying at 100%, less deductibles and copays. High Deductible Health Plan (HDHP): The portion of coinsurance a covered person pays for certain services before we begin paying at 100%, including deductibles and copays.	Let’s say you have a $1,000 deductible and $3,000 OOPM. Humana pays 80% of eligible in-network health care costs. Once you reach your OOPM (paid your $1,000 deductible AND your $3,000 out-of-pocket limit in coinsurance). Humana pays 100% of eligible, in-network health care costs.
Network Provider	A hospital, health care treatment facility, health care 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 336,000 doctors are members of Humana’s network and provide discounts to Humana health plan members.
Rating Area	This is an area used for determining premium rates, usually by ZIP Code. The premium is based on the average health care costs and physician/hospital discounts in that area.	HumanaOne’s premium rates reflect the physician and hospital discounts in a particular area. This is yet another way Humana’s network strength benefits you.
Maximum Allowable Fee	The lesser of: The fee charged by the provider for the services; The fee that has been negotiated with the provider whether directly or through one or more intermediaries, or shared savings contracts for the services; The fee established by us by comparing rates from one or more regional or national databases or schedules for the same or similar services from a geographic area determined by us; The fee based on rates negotiated by us or other payors with one or more network providers in a geographic area determined by us for the same or similar services; The 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 and Medicaid Services (CMS) annually; or The 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, 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 will not apply to the out-of-pocket limit or deductible.