Page numbers referenced within this brochure apply only to the printed brochure

Humana Health Plan, Inc.

https://feds.humana.com/
Customer Service 1-800-4HUMANA

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization
(High, Standard and Basic Option)

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 8 for details. This plan is accredited. See page 13.

Serving: Central and Northwestern Illinois, Chicago, IL Metropolitan Area, Denver and Colorado Springs, CO

Enrollment in this Plan is limited. You must live or work in
our geographic service area to enroll. See page 14 for
requirements.

Enrollment codes for this Plan:

Central and Northwestern, IL: 
9F1
High Option - Self Only
9F3 High Option - Self Plus One
9F2 High Option - Self and Family
AB4 Standard Option - Self Only
AB6 Standard Option - Self Plus One
AB5 Standard Option - Self and Family
AB1 Basic Option - Self Only
AB3 Basic Option - Self Plus One
AB2 Basic Option - Self and Family

Chicago, IL:
751
High Option - Self Only 
753 High Option - Self Plus One
752 High Option - Self and Family 
754 Standard Option - Self Only 
756 Standard Option - Self Plus One
755 Standard Option - Self and Family
RW1 Basic Option - Self Only
RW3 Basic Option - Self Plus One
RW2 Basic Option - Self and Family

Colorado Springs, CO:
NR1 High Option - Self Only
NR3 High Option - Self Plus One
NR2 High Option - Self and Family
NR4 Standard Option - Self Only
NR6 Standard Option - Self Plus One
NR5 Standard Option - Self and Family
R21 Basic Option - Self Only
R23 Basic Option - Self Plus One
R22 Basic Option - Self and Family


Denver, CO:
NT1 High Option - Self Only
NT3 High Option - Self Plus One
NT2 High Option - Self and Family
NT4 Standard Option - Self Only
NT6 Standard Option - Self Plus One
NT5 Standard Option - Self and Family
RZ1 Basic Option - Self Only
RZ3 Basic Option - Self Plus One
RZ2 Basic Option - Self and Family

Federal Employees Health Benefits Program seal
OPM Logo








Important Notice

Important Notice from Humana Health Plan, Inc. About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Humana Health Plan, Inc. prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage.  This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage.  If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at
www.socialsecurity.gov, or call the SSA at 1-800-772-1213, (TTY 1-800-325-0778)

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of Humana Health Plan, Inc. under contract (CS 1570) between Humana and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer Service may be reached at 1-800-4HUMANA, 1-800-448-6262 or through our website: http://feds.humana.com. The address for the Humana Health Plan, Inc. administrative offices is:

In Chicago, Central and Northwest, IL:

Humana Health Plan, Inc.
550 West Adams Street, Suite 6
Chicago, Illinois 60661

In Colorado Springs and Denver, CO:

Humana Health Plan, Inc.
6300 S. Syracuse Way, Suite 555
Centennial, Colorado 80111

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this brochure. 

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page 15. Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Humana Health Plan, Inc.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us at 1-800-4HUMANA and explain the situation.

If we do not resolve the issue: 

CALL- THE HEALTHCARE FRAUD HOTLINE
1-877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/. The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time. 

You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

  • A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment. Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless they were disabled and incapable of self-support prior to age 26)
  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Humana Health Plan, Inc. complies with all applicable Federal civil rights laws, including both Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:
Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Attention:  Assistant Director, FEIO
1900 E Street NW, Suite 3400-S
Washington, D.C. 20415-3610

If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Discrimination Grievances,
P.O. Box 14618, Lexington, KY 40512-4618.

Multi-Language Interpreter Services

English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-800-448-6262, TTY 711.

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-448-6262, TTY 711.

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-448-6262, TTY 711.

Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-448-6262, TTY 711.

Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-448-6262, ATS 711.

Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-448-6262, TTY 711.

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sial’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-448-6262, TTY 711.

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-448-6262, TTY 711.




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, or through the Plan or Provider’s portal?
  • Do not assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
  • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:

- "Exactly what will you be doing?"
- "About how long will it take?"
- "What will happen after surgery?"
- "How can I expect to feel during recovery?"

  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit

  • www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.
  • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
  • www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
  • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use Humana preferred providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.




FEHB Facts

Coverage information




TermDefinition

No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

  • When you may change your enrollment
  • How you can cover your family members
  • What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
  • What happens when your enrollment ends
  • When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact Humana directly for address updates and questions about your benefit coverage.

Types of coverage available for you and your family

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family member. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. 

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren

Coverage: Natural children, adopted children and stepchildren are covered until their 26th birthday. 

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information. 

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

  • If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
  • If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
  • If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. 

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2022 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).




When you lose benefits




TermDefinition

When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

  • Your enrollment ends, unless you cancel your enrollment; or
  • You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage throughthe Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

Converting to individual coverage

You may convert to a non-FEHB individual policy if:

  • Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
  • You decided not to receive coverage under TCC or the spouse equity law; or
  • You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact customer service on the back of your ID card or visit www.HealthCare.gov.

Health Insurance Marketplace

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Humana holds the following accreditation: The National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation, please visit the following websites: www.ncqa.gov.

We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers
coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, a Standard Option, or a Basic Option.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

General features of our High, Standard and Basic Options

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles and non-covered services and supplies).

Who provides my healthcare?

Humana Health Plan, Inc. offers members an extensive choice of primary care physicians that are listed in the Plan’s Provider Directory. Care is provided by doctors, nurse practitioners, and other skilled medical personnel. If care is needed by specialists not represented on the Plan staff, a Plan doctor will refer you to a specialist in the community without any additional cost to you other than the assigned copayment.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The annual out-of-pocket expenses for covered services, including deductibles and copayments, cannot exceed $8,150 for Self Only enrollment, and $16,300 for Self Plus One or Self and Family. 

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below.

  • Nationally, Humana has been in the healthcare business since 1961.
  • Locally, Humana Health Plan has been in existence since 1984.
  • Humana is a for profit corporation which is publicly traded on the New York Stock Exchange (NYSE).

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, OPM’s FEHB (www.opm.gov/healthcare-insurance/). You can also contact us to request that we mail a copy to you.

If you want more information about us, call 1-800-4HUMANA, or write to the Plan at P.O. Box 14601, Lexington, KY 40512-4601. You may also visit our website at http://feds.humana.com.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website http://feds.humana.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail a copy of that notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area is:

The Greater Chicago service area:

  • The Illinois counties of Cook, DuPage, Kane, Kankakee, Kendall, Lake, McHenry and Will. 
  • The Indiana counties of Lake, LaPorte and Porter. 

The Central and Northwestern Illinois counties of Boone, Bureau, DeKalb, Dewitt, Fulton, Henderson, Henry, Knox, LaSalle, Lee, Livingston, Marshall, McDonough, McLean, Mercer, Ogle, Peoria, Putnam, Stark, Stephenson, Tazewell, Warren, Whiteside, Winnebago, and Woodford.

The Denver, Colorado counties of Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, and Jefferson.

The Colorado Springs, Colorado counties of El Paso and Teller.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans.  Contact your employing or retirement office.
 




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes:

  • Effective in 2022, premium rates are the same for Non-Postal and Postal employees

Changes to the High, Standard and Basic Options:

  • Colorado Springs, CO - Enrollment code NR (High Option) - Your share of the premium rate will increase for Self Only and Self Plus One. (See page 89)
  • Colorado Springs, CO - Enrollment code NR (High Option) - Your share of the premium rate will decrease for Self and Family. (See page 89)
  • Colorado Springs, CO - Enrollment code NR (Standard Option) - Your share of the premium rate will remain the same for Self Only, Self Plus One, and Self and Family. (See page 89)
  • Colorado Springs, CO - Enrollment code R2 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 89)
  • Denver, CO - Enrollment code NT (High Option) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 89)
  • Denver, CO - Enrollment code NT (Standard Option) - Your share of the premium rate will remain the same for Self Only, Self Plus One, and Self and Family. (See page 89)
  • Denver, CO - Enrollment code RZ - Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family. (See page 90)
  • Central and Northern Illinois - Enrollment code 9F - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 90)
  • Central and Northern Illinois - Enrollment code AB - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 90)
  • Chicago, IL-Enrollment code 75 (High/Standard Self Only/Self Plus One)-Your share of the premium rate will increase. 
  • Chicago, IL - Enrollment code 75 - (High /Standard Family) Your share of the premium rate for the High Option will increase and the Standard Option will decrease. (See page 90)
  • Chicago, IL - Enrollment code RW - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 90)

Changes to the Basic Option:

  • Inpatient services: Your inpatient hospital benefit will change from $900 copayment per day for the first three (3) days per admission to $900 copayment per day for the first five (5) days per admission.

Changes to this Plan:

  • Medicare Coordination of Benefits: Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.



Section 3. How You Get Care

TermDefinition

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-4HUMANA or 1-800-448-6262, or write to us at P.O. Box 14604, Lexington, KY 40512-4604. You may also request replacement cards through our website at http://feds.humana.com.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments or coinsurance, and you will not have to file claims.

Plan providers

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website at http://feds.humana.com.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall health care needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at https://feds.humana.com.

Balance Billing Protection

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact Humana to enforce the terms of its provider contract.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your healthcare. You may choose your primary care physician from our Provider Directory or our website, or you may call us for assistance.

Primary care

Your primary care physician can be a family practitioner, general practitioner, internist, or pediatrician. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see the following participating providers without a referral:

  • Mental health providers
  • Vision care providers
  • OB/GYN providers for your annual well-woman exam
  • Another doctor your primary care physician has designated to provide patient care when he or she is not available.

Here are some other things you should know about specialty care:

  • If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.

Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If they decide to refer you to a specialist, ask if you can see your current specialist.

If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

  • If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
  • If you have a chronic and disabling condition and lose access to your specialist because we:
    • terminate our contract with your specialist for other than cause;
    • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
    • reduce our Service Area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

If you are a Colorado member, and if the rendering provider is contracted for the Colorado HMOx network, the referral requirement is waived.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

  • If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-426-2173. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered expenses while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

  • you are discharged, not merely moved to an alternative care center;
  • the day your benefits from your former plan run out; or
  • the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

Inpatient hospital admission

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. 

Other services

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:

  • Organ/tissue transplants
  • All elective medical and surgical hospitalizations (Including Inpatient Hospice)
  • Non emergent admissions for mental health, skilled nursing, acute rehabilitation facilities and long term acute care  facilities
  • MRI, MRA, PET, CT Scan, SPECT Scan
  • Surgical treatment for morbid obesity
  • All durable medical equipment (DME) over $750
  • Home healthcare services (Including Home Hospice)
  • Infertility testing and treatment
  • Some specialty drugs when delivered in the physician’s office, clinic, outpatient or home setting
  • All surgeries which may be considered plastic or cosmetic surgery only for repair of accidental injury
  • Oral surgeries
  • Outpatient Therapy Services for Physical, Occupational, and Speech
  • Genetic/Molecular Diagnostic Testing – (Genetic testing is covered under the laboratory services benefit, limitations may apply.)
  • Chiropractic
  • Radiation Therapy
  • Acupuncture
  • Esophagogastroduodenoscopy (EGD)
  • Coronary angiography
  • Colonoscopy repeat testing

For a complete listing of services requiring prior authorization, please visit our website at www.humana.com. See commercial list.

How to request precertification for an admission or get prior authorization for Other services

First, your physician, your hospital, you, or your representative must call us at the phone number printed on your Humana ID card or 1-800-4HUMANA before admission or services requiring prior authorization are rendered.

Next, provide the following information:

  • enrollee's name and Plan identification number;
  • patient's name, birth date, identification number and phone number;
  • reason for hospitalization, proposed treatment, or surgery;
  • name and phone number of admitting physician;
  • name of hospital or facility; and
  • number of days requested for hospital stay.

Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at
1-800-4HUMANA or 1-800-448-6262. You may also call OPM’s FEHB 3 at 1-(202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 1-800-4HUMANA or 1-800-448-6262. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

The Federal Flexible Spending Account Program – FSAFEDS

  • HealthCare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Maternity care

Precertification is not required for maternity care.

If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

What happens when you do not follow the precertification rules when using non-network facilities. 

This plan does not offer out-of-network  coverage, except for emergent care situations. If no authorization is received or approved, you will be responsible for all costs of such services.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you disagree with our pre-service claim decision

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

  1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
  2. Ask you or your provider for more information. 

    You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. 

    If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
  3. Write to you and maintain our denial.

To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.




Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:



TermDefinition
Cost-sharingCost-sharing is the general term used to refer to your out-of-pocket costs (e.g. deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care physician, you pay a copayment of $20 per office visit with the High Option, $35 with the Standard Option or $50 with the Basic Option.

DeductibleWe do not have a deductible.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: You pay 50% of charges for infertility services.

Differences between our Plan allowance and the bill

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Your catastrophic protection out-of-pocket maximum

After your (copayments and coinsurance) total $8,150 for Self Only, or $16,300 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.

The maximum annual limitation on cost sharing listed under Self Only of $8,150 for the High, Standard and Basic Option plan applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your plan has a $8,150 Self Only maximum out-of-pocket limit and a $16,300 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $8,150 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $16,300, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $16,300 for the calendar year before their qualified medical expenses will begin to be covered in full. 

Be sure to keep accurate records and receipts of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.

Carryover

If you changed to this plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

When Government facilities bill us

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

Important Notice About Surprise Billing – Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. 

In addition, your health plan adopts and complies with the surprise billing laws of Colorado and Illinois.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to https://humana.com or contact the health plan at 1-800-4HUMANA.




Section 5. High, Standard and Basic Option Benefits (High, Standard and Basic Option)

See page 15 for how our benefits changed this year. Pages 86, 87 and 88 are a benefits summary of each option. Make sure that you review the benefits that are available under the option in which you are enrolled.




(Page numbers solely appear in the printed brochure)




Section 5. High, Standard and Basic Option Benefits Overview

This Plan offers a High, Standard and Basic Option. All benefit packages are described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The High, Standard and Basic Options Section 5 is divided into subsections. Please read important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about High, Standard and Basic Option benefits, contact us at 1-800-4HUMANA or on our Web site at http://feds.humana.com.

Network Availability

Illinois - Humana contracts with both private office physicians and with physician groups. Referrals are required for participating providers. The Illinois HMO plans for Chicago utilize the Illinois Platinum HMO network and Central Illinois utilize the HMO Premier network.   

Colorado - If you are a Colorado member, and if the rendering provider is contracted for the Colorado HMOx network, the referral requirement is waived. The Colorado plans will utilize the Colorado HMOx network.

Pharmacy

Your pharmacy plan is an Rx5 Plan, which allows members access to appropriate drugs used to treat conditions the medical plan covers. See drug levels listed below:

  • Level One – preferred generic and lowest-cost generic
  • Level Two – non-preferred generic and low-cost generic
  • Level Three – preferred brand and higher-cost generic
  • Level Four – non-preferred brand and some non-preferred higher-cost generics
  • Level Five – most self-administered injectable medications and high-technology drugs that are often newly approved by the U.S. Food and Drug Administration.

Check your pharmacy and drug coverage details at MyHumana.com.

feds.Humana.com

Online tools include:

  • Newly hired employees can easily navigate their plan choices
  • Ability to view benefits and rates available to you based on service area ZIP code
  • Learn “What’s New” about Humana’s plan offerings and other health topics
  • Enroll in medical plans online
  • Educate yourself about Humana’s health and wellness programs
  • Find in-network doctors, hospitals and pharmacies near you
  • Search Humana’s Drug List for prescription drugs and their estimated retail prices



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works.  Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.




Benefit Description : Diagnostic and treatment servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Professional services of physicians

  • In physician’s office
  • Office medical consultations
  • At home
  • Second surgical opinion
  • Advance care planning

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

  • During a hospital stay
  • In a skilled nursing facility

Nothing

Nothing

Nothing

  • In an urgent care center
$40 copay per visit

$55 copay per visit

$70 copay per visit

Benefit Description : Telehealth servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Telemedicine (also known as telehealth," "virtual visits" or “video visits”) uses information technology and telecommunications to provide virtual clinical care to patients. Patients can interact with Network Primary/Specialty Care providers through video and app technology by using smartphones, tablets, and laptops.

With Humana's telemedicine benefit delivered by Doctor On Demand, you can:

  • Connect with a physician from one of Doctor On Demand’s U.S. board-certified doctors
  • Immediately see a doctor 24 hours a day, 7 days a week from any location
  • Your primary care physician can access your telemedicine visit at your request
  • If medically necessary, the telemedicine doctor can send a prescription to a preferred pharmacy

Note: In addition to using Doctor On Demand for telehealth visits, you can talk to other providers to see if they are offering video chat or phone-only visits at normal cost-share.

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

$50 copay per office visit to your primary care physician

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap test
  • Pathology
  • X-ray
  • Non-routine mammogram
  • Ultrasound
  • Electrocardiogram and EEG
  • Coronary angiography (Note: See You need prior plan approval for certain services in Section 3)

Note: See Section 5(c) for some services billed by a facility, such as the outpatient department of a hospital.

Nothing

Nothing

Nothing

Other tests:

  • Genetic counseling and Genetic testing when medically necessary. (Note: See You need prior plan approval for certain services in Section 3)

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

Benefit Description : Preventive care, adultHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Routine physical every year

The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at
    https://www.healthcare.gov/preventive-care-women/
  • To build your personalized list of preventive services go to  https://health.gov/myhealthfinder
NothingNothing

Nothing

Routine mammogram – covered for women

Nothing

Nothing

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC):based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing

Nothing

Nothing

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Nothing

Not covered: 

  • Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
  • Immunizations, boosters, and medications for travel or work-related exposure.
All chargesAll charges

All charges

Benefit Description : Preventive care, childrenHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
NothingNothing

Nothing

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Nothin

Benefit Description : Maternity careHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Complete maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women
  • Delivery
  • Postnatal care

Nothing

Facility copay applies to Delivery

 

 

  

Nothing

Facility copay applies to Delivery

 

 

Nothing

Facility copay applies to Delivery

Breastfeeding support, supplies and counseling for each birth 

Nothing

Nothing

Nothing

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay for you or your baby, if medically necessary.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • We offer HumanaBeginnings. See Special features in Section 5(h).
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Nothing

Nothing

Nothing

Benefit Description : Family planning High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

  • Voluntary sterilization (See Surgical procedures Section 5(b))
  • Surgically implanted contraceptives
  • Contraceptive devices
  • Injectable contraceptive drugs (such as Depo-Provera)
  • Intrauterine devices (IUDs)
  • Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit. See Section 5(f).

NothingNothing

Nothing

Not covered: 

  • Reversal of voluntary surgical sterilization
All chargesAll charges

All charges

Benefit Description : Infertility servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Infertility is the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For women without male partners or exposure to sperm, infertility is the inability to conceive after six cycles of Artificial Insemination or Intrauterine Insemination performed by a qualified specialist using normal quality donor sperm. These 6 cycles (including donor sperm) are not covered by the plan as a diagnosis of infertility is not established until the cycles have been completed.

Covered benefits including evaluation and treatment:

Females - ovulation evaluation, tubal patency, hormonal evaluation, and cervical factor evaluation.

Males – includes sperm analysis, hormonal analysis, sperm functioning and medical imaging. Treatment would include correction of any defect found in the evaluation of both male and female partners.

Diagnosis and treatment of infertility, such as:

  • Artificial insemination:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
  • Fertility drugs

Note: Self-injectable and oral fertility drugs are covered under the Prescription Drug Benefit. (See You need prior plan approval for certain services in Section 3.)

50% of charges

50% of charges

50% of charges

Not covered:

  • Assisted reproductive technology (ART) procedures, such as:
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian tranfser (ZIFT)
  • Services and supplies related to excluded ART procedures
  • Cost of donor sperm
  • Cost of donor egg
All chargesAll charges

All charges

Benefit Description : Allergy careHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Testing and treatment

 

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

  • Allergy serum
  • Allergy injections
NothingNothing

Nothing

Not covered: 

  • Provocative food testing
  • Sublingual allergy desensitization
All chargesAll charges

All charges

Benefit Description : Treatment therapiesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Chemotherapy and radiation therapy (Note: See You need prior plan approval for certain
    services in Section 3)

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 42.

Note: Oral Chemo medications are covered under the Pharmacy benefit. (See Section 5(f) for details)

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided. No visit limitations apply
  • Dialysis – hemodialysis and peritoneal dialysis
  • Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy (See You need prior plan approval for certain services in Section 3).
  • Growth hormone therapy (GHT)

Note: Growth hormone is covered under the Prescription Drug benefit. We only cover GHT when we preauthorize the treatment. Your Plan Physician will ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3 under Other services.

Note: Applied Behavior Analysis (ABA) Children with Autism Spectrum Disorder is described in Section 5(e).

$40 copay per office visit to a specialist

$55 copay per office visit to a specialist

$70 copay per office visit to a specialist

  • Applied Behavior Analysis (ABA) Children with Autism Spectrum Disorder

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

Benefit Description : Physical, occupational and cardiac therapiesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Up to 60 visits per year per condition for the services of each of the following:

  • Qualified physical therapists
  • Occupational therapists

Note:  We only cover therapy when a physician

  • orders the care,
  • identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
  • indicates the length of time the services are needed.

Note: See You need prior plan approval for certain services in Section 3.

$40 copay per office visit to a specialist

$55 copay per office visit to a specialist

$70 copay per office visit to a specialist

  • Habilitative services up to 60 visits per year

$40 copay per office visit to a specialist.

$55 copay per office visit to a specialist.

$70 copay per office visit to a specialist.

Not covered:

  • Long-term rehabilitative therapy
  • Exercise Programs
All charges All charges

All charges

Benefit Description : Speech therapy High Option (You pay )Standard Option (You pay )Basic Option (You pay )

60 visits per condition per year for the service of the following:

  • Speech therapists

Note: See You need prior plan approval for certain services in Section 3.

$40 copay per visit

$55 copay per visit

$70 copay per visit

Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Hearing screening performed during a child's preventive care visit, see Section 5(a) - Preventive care, children.
NothingNothing

Nothing

  • Cochlear Implants

20% coinsurance

30% coinsurance

50% coinsurance

Not covered:

  • Hearing services that are not shown as covered
All chargesAll charges

All charges

Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Diagnosis and treatment of diseases of the eye
  • Annual eye refractions to provide a written lens prescription for eyeglasses
  • One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

  • Screening eye exam to determine the need for vision correction for children through age 17

Note: See Preventive care, children.

NothingNothing

Nothing

Not covered:

  • Eye exercises and orthoptics
  • Contact lenses examination
  • Radial keratotomy and other refractive surgery
All charges All charges

All charges

Benefit Description : Foot careHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
All charges All charges

All charges

Benefit Description : Orthopedic and prosthetic devices High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
  • Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. 

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

20% coinsurance

30% coinsurance

50% coinsurance

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Prosthetic replacements except as required by growth or change in medical condition
All chargesAll charges

All charges

Benefit Description : Durable medical equipment (DME)High Option (You pay )Standard Option (You pay )Basic Option (You pay )

We cover rental or purchase of durable medical equipment, at our option, including repair and maintenance of purchased medical equipment. 

Covered items include:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers
  • Insulin pumps and supplies
  • Blood glucose monitors
  • Communication devices

Note: Communication devices covered for members who have had surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx.

Note: Preauthorization is necessary for items over $750. See You need prior plan approval for certain services in Section 3.

20% coinsurance

30% coinsurance

50% coinsurance

Not covered:

  • Equipment such as exercise equipment, air cleaners, heating pads or lights, and bed lifts, hearing aids, personnel hygiene equipment.
  • Communication devices except for those members who have had surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx.
All chargesAll charges

All charges

Benefit Description : Home health servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
  • Services include oxygen therapy, intravenous therapy and medications.

See You need prior plan approval for certain services in Section 3.

$40 copay per visit

$55 copay per visit

$70 copay per visit

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family.
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
  • Private duty nurse.
All chargesAll charges

All charges

Benefit Description : Chiropractic High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Spinal manipulations, adjustments and modalities limited to a combined maximum of 20 visits per year

See You need prior plan approval for certain services in Section 3.

$40 copay per visit

$55 copay per visit

$70 copay per visit

Benefit Description : Alternative treatmentsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Acupuncture – by a licensed acupuncturist for:

  • anesthesia
  • pain relief

See You need prior plan approval for certain services in Section 3.

$40 copay per visit

$55 copay per visit

$70 copay per visit

Not covered:

  • Naturopathic services
  • Hypnotherapy
  • Biofeedback
All chargesAll charges

All charges

Benefit Description : Educational classes and programsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Coverage is provided for:

  • Tobacco Cessation program benefits, including individual, group and phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
  • Childhood obesity education
NothingNothing

Nothing

  • Diabetes self management training

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.  Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.




Benefit Description : Surgical proceduresHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Surgical treatment for morbid obesity (bariatric surgery). (Note: See You need prior plan approval for certain services in Section 3). Some of the requirements that must be met before surgery can be authorized are:
    • Patient is 18 years of age or older
    • Body Mass Index of >40, or a Body Mass Index of >35 with associated comorbidity such as:
      • Hypertension
      • Type two diabetes
      • Life-threatening cardiopulmonary problems
    • Physician's documentation which indicates that you have had unsuccessful attempt(s) with nonoperative medically- supervised weight-reduction program(s)
  • Insertion of internal prosthetic devices. See Section 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
  • Treatment of burns
  • Esophagogastroduodenoscopy (EGD) (Note: See You need prior plan approval for certain services in Section 3)
  • Colonoscopy repeat testing (Note: See You need prior plan approval for certain services in Section 3)

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

NothingNothing

Nothing

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; (see 5(a) Foot care)
All chargesAll charges

All charges

Benefit Description : Reconstructive surgery High Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and that is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Orthopedic and Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

  • Gender reassignment surgery performed to change primary and/or secondary sex characteristics
    • Surgical treatment for gender reassignment is limited to the following:
      • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy
      • For male to female surgery: penectomy, orchiectomyGender reassignment surgery performed to change primary and/or secondary sex characteristics

Note: You must be 18 years or older to be considered for genital reconstruction surgery. There are pre-surgical requirements for members considering gender reassignment surgery including but not limited to: a documented diagnosis of gender dysphoria, 12 months of hormone therapy as appropriate to the individual gender goals, and referral letters from a mental health specialist.

NothingNothing

Nothing

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury (Note: See You need prior plan approval for certain services in Section 3)
  • Any surgical procedure for gender reassignment not listed above
All chargesAll charges

All charges

Benefit Description : Oral and maxillofacial surgery High Option (You pay )Standard Option (You pay )Basic Option (You pay )

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip or cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and incision of abscesses when done as independent procedures;
  • Excision of partially or completely impacted teeth;
  • Diagnosis and treatment specifically directed toward medical and functional disorders of the temporomandibular joint (TMJ);
  • Other surgical procedures that do not involve the teeth or their supporting structures
NothingNothing

Nothing

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
  • Dental work related to treatment for temporomandibular joint syndrome (TMJ)
All charges All charges

All charges

Benefit Description : Organ/tissue transplantsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

These solid organ transplants are covered. Solid organ transplants are limited to:

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney-pancreas
  • Liver
  • Lung: single/bilateral/lobar
  • Pancreas
NothingNothing

Nothing

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

Nothing

Nothing

Nothing

Blood or marrow stem cell transplants The Plan extends coverage for the diagnoses as indicated below.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic
      (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann’s syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders
      (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic
      (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast Cancer
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Ewing’s sarcoma
    • Multiple myeloma
    • Medulloblastoma
    • Pineoblastoma
    • Neuroblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Nothing

Nothing

Nothing

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic
      (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic
      (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

Nothing

Nothing

Nothing

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Allogeneic transplants for
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Sickle Cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
    • Acute lymphocytic or non-lymphocytic 
      (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphomas
    • Breast cancer
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative disorders (MPDs)
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous Transplants for
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphomas
    • Breast cancer
    • Childhood rhabdomyosarcoma
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial ovarian cancer
    • Mantle cell (non-Hodgkin lymphoma)
    • Multiple sclerosis
    • Small cell lung cancer
    • Systemic lupus erythematosus
    • Systemic sclerosis

Benefits are available for Allogeneic and Autologous blood or marrow stem cell transplants utilizing a phase two or higher protocol.

Nothing

Nothing

Nothing

National Transplant Program (NTP) - all services are determined and authorized through our transplant department, utilizing our National Transplant Network.

Nothing

Nothing

Nothing

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or bone marrow/stem cell transplant donors in addition to the testing of family members.

See You need prior plan approval for certain services in Section 3. 

Nothing

Nothing

Nothing

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
All chargesAll charges

All charges

Benefit Description : AnesthesiaHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Professional services provided in –

  • Hospital (inpatient)
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgical center
  • Office
NothingNothing

Nothing




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
  • Be sure to read Section 4, Your cost for covered services for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge
    (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.
  • Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.




Benefit Description : Inpatient hospitalHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)

Room and board, such as:

  • Ward, semiprivate, intensive care or cardiac care accommodations
  • General nursing care
  • Private accommodations when medically necessary
  • Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$400 copayment per day for the first three (3) days per admission

$600 copayment per day for the first three (3) days per admission

$900 copayment per day for the first five (5) days per admission

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Take-home items
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
NothingNothing

Nothing

Not covered:

  • Blood and blood components if not replaced
  • Non-covered facilities, such as nursing homes, schools
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
All chargesAll charges

All charges

Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)
  • Pre-surgical testing
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests, X-rays, and pathology services
  • Administration of blood, blood plasma, and other biologicals
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia

$400 copay per visit

$500 copay per visit

$700 copay per visit

  • Outpatient services, such as: MRI, MRA, CT, PET, and SPECT

(Note: See You need prior plan approval for certain services in Section 3)

$200 copay per visit$250 copay per visit

$300 copay per visit

  • Voluntary sterilization
NothingNothing

Nothing

  • Other outpatient non-surgical care such as mammograms, laboratory tests and X-rays

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

NothingNothing

Nothing

Not covered:

  • Blood and blood components, if not replaced
All chargesAll charges

All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)

Extended care benefit:

Up to 100 days per calendar year, including:

  • Bed and board
  • General nursing care
  • Drugs, biologicals, supplies and equipment provided by the facility

Note: Coverage is provided when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

$400 copay per day for the first three (3) days per admission

$600 copay per day for the first three (3) days per admission

$900 copay per day for the first three (3) days per admission

Not covered: 

  • Custodial care
All chargesAll charges

All charges

Benefit Description : Hospice careHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility.  

Services include:

  • Inpatient care
  • Outpatient care
  • Bereavement counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

See You need prior plan approval for certain services in Section 3.

NothingNothing

Nothing

Not covered: 

  • Independent nursing
  • homemaker services
All chargesAll charges

All charges

Benefit Description : End of life careHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)

Personal Nurse provides the following end-of-life support:

  • Hospice coordination
  • Education and support services
  • Humana At Home Coordination

Nothing

Nothing

Nothing

Benefit Description : AmbulanceHigh Option (You pay)Standard Option (You pay)Basic Option (You pay)

Local professional ambulance service when medically appropriate

$50 copay

$50 copay

$50 copay




Section 5(d). Emergency Services/Accidents (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.




What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.




What to do in case of emergency:

Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.




Benefit Description : Emergency within our service areaHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Emergency care at a doctor’s office

$20 per office visit to your primary care physician

$40 per office visit to a specialist

$35 per office visit to your primary care physician

$55 per office visit to a specialist

$50 per office visit to your primary care physician

$70 per office visit to a specialist

  • Emergency care at an urgent care center
$40 per visit

$55 per visit

$70 per visit

  • Emergency care as an outpatient at a hospital, including doctors’ services

Note: If admitted, hospital copays apply. See Section 5(c) for Inpatient hospital services.

$200 per visit

$250 per visit

$325 per visit

Not covered: 

  • Elective care or non-emergency care
All chargesAll charges

All charges

Benefit Description : Emergency outside our service areaHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Emergency care at a doctor’s office

$20 per office visit to a primary care physician

$40 per office visit to a specialist

$35 per office visit to a primary care physician

$55 per office visit to a specialist

$50 per office visit to a primary care physician

$70 per office visit to a specialist

  • Emergency care at an urgent care center
$40 per visit

$55 per visit

$70 per visit

  • Emergency care as an outpatient at a hospital, including doctors’ services

Note: If admitted, hospital copays apply. See Section 5(c) for Inpatient hospital services.

$200 per visit

Note: Copay is waived if admitted

$250 per visit

Note: Copay is waived if admitted

$325 per visit

Note: Copay is waived if admitted

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
  • Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
All charges All charges

All charges

Benefit Description : AmbulanceHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Professional ambulance service

Note: See Section 5(c) for non-emergency service.

Note: Air ambulance is covered only when point of pick-up is inaccessible by land vehicle; or great distances or other obstacles are involved in getting a patient to the nearest hospital with appropriate facilities when prompt admission is essential.

$50 copay

$50 copay

$50 copay

Benefit Description : Telehealth servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Telemedicine (also known as “telehealth,” "virtual visits" or “video visits”) uses information technology and telecommunications to provide virtual clinical care to patients. Patients can interact with Network Primary/Specialty Care providers through video and app technology by using smartphones, tablets, and laptops.

With Humana's telemedicine benefit delivered by Doctor On Demand, you can:

  • Connect with a physician from one of Doctor On Demand’s U.S. board-certified doctors
  • Immediately see a doctor 24 hours a day, 7 days a week from any location
  • Your primary care physician can access your telemedicine visit at your request
  • If medically necessary, the telemedicine doctor can send a prescription to a preferred pharmacy

$20 per office visit to your primary care physician

$35 per office visit to your primary care physician

$50 per office visit to your primary care physician




Section 5(e). Mental Health and Substance Use Disorder Benefits (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOUR MENTAL HEALTH PROFESSIONAL MUST GET CERTIFICATION FOR SOME MENTAL HEALTH VISITS AND SERVICES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.



Benefit Description : Professional servicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

When we approve a treatment plan, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists. 

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Diagnostic evaluation
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management  (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy
$20 copay per visit

$35 copay per visit

$50 copay per visit

Benefit Description : DiagnosticsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Outpatient diagnostic tests and services such as: MRI, MRA, CT, PET, and SPECT when provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility
NothingNothing

Nothing

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Inpatient services provided and billed by a hospital or other covered facility, including residential facilities

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services, including Telemedicine.

$400 copay per day for the first three (3) days per admission

$600 copay per day for the first three (3) days per admission

$900 copay per day for the first five (5) days per admission

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Outpatient services provided and billed by a hospital or other covered facility, including residential facilities

  • Services in approved treatment programs, such as partial hospitalization or full-day hospitalization
NothingNothing

Nothing

  • Facility-based intensive outpatient treatment

Nothing

Nothing

Nothing

Benefit Description : Applied behavior analysis (ABA) therapyHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
Applied Behavior Analysis (ABA) therapy for Autism Spectrum Disorder

$20 copay per office visit to your primary care physician.

$35 copay per office visit to your primary care physician.

.

$50 copay per office visit to your primary care physician.

.

Benefit Description : Other ServicesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )
  • Urgent Care
  • Physical, Occupational, Speech and Habilitative therapies for Mental Health (Note: See You need prior plan approval for certain services in Section 3)
  • Nutritional Counseling for Eating Disorders

$20 copay per visit

$35 copay per visit

$50 copay per visit

Benefit Description : Not coveredHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

Services that are not part of a preauthorized approved treatment plan

All charges

All charges

All charges




Section 5(f). Prescription Drug Benefits (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on the next page.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.




There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a prescribed maintenance medication. Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries. Members in Illinois can also fill their maintenance medications for 90 days at a retail pharmacy for their appropriate copayment. 
  • The Rx5 Plan allows members access to appropriate drugs which are used to treat conditions the medical plan covers. Thousands of drugs have been placed in levels based on their a) efficacy, b) safety, c) possible side effects, d) drug interactions, and e) cost compared to similar drugs. New drugs are continually reviewed for level placement, dispensing limits, step therapy and prior authorization requirements that represent the current clinical judgment of our Pharmacy and Therapeutics Committee. Some medications are considered non-formulary because there are other lower cost therapeutic alternatives available on the formulary. 

Level One contains/covers Preferred generic and lowest cost generic.

Level Two contains/covers non-Preferred generic and low cost generic.

Level Three contains/covers Preferred brand and higher cost generic.

Level Four contains/covers non-preferred brand and some non-preferred higher cost generics

Level Five contains specialty drugs and includes most self administered injectable medications and high technology drugs that are often newly approved by the U.S. Food and Drug Administration (specialty drugs may be limited to a 30-day supply). For some specialty drugs, see You need prior plan approval for certain services in Section 3.

With Rx5 the member takes on more of the cost share for the drug. In return, members receive access to more drugs to treat their conditions and have more choices, along with their physicians, to decide which drug to take. Members receive letters offering guidance in changing medications to those with a lower copayment. We use internal data to identify members for whom a less expensive prescription drug option may be available. We communicate the information to the member to enable them, along with their physician, to make an informed choice regarding prescription drug copayment options.

  • Prior Authorization:  Some medications need special monitoring and may require prior authorization. These drugs have different approval criteria based on indication, safety and appropriate use. Prior authorization (PA) requires a physician to obtain pre-approval in order to provide coverage for a drug prescribed to a member.
  • Step Therapy: Step Therapy directs therapy to the most cost-effective and safest drug available to be used prior to moving to a more costly or risky therapy. Step Therapy is an automated process and requires the member to try Alternative medications before the more costly medications are considered. 

  • These are the dispensing limitations. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 30-day supply. You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program or at one of our retail pharmacies. Specialty drugs are limited to a 30-day supply. You must use dispensing limitations as directed, unless provider instructs otherwise.

  • Why use generic drugs? Generic medications have the same benefits, ingredients and safety as brand-name medications but without the high dollar cost. With the price of prescription medicine rising, it’s nice to find where you can save money without compromising on quality.
  • When you do have to file a claim? For out of network claims, please contact Humana’s customer service for reimbursement.

If there is a national emergency or you are called to active military duty, you may call 1-800-448-6262. A representative will review criteria to determine whether you may obtain more than your normal dispensing amount.

  • Non-formulary. Medicine(s) are not in your plan's drug list (which means you pay the full cost of the prescription). Your doctor can ask Humana to make an exception to cover your non-formulary medicine if he or she believes the alternative covered drugs won't be as effective in treating your health condition and/or would cause a bad reaction.

When brand name drugs are purchased and a generic is available, you must pay the difference between the brand name and generic cost plus any applicable brand copay, unless the physician writes "dispense as written" on the prescription. The physician must write "dispense as written" on the prescription for you to receive a brand name drug and only pay the brand name copay, if a generic is available.

You can visit our web site at http://feds.humana.com to check the copayment for your prescription drug coverage before you get your prescription filled. You can also find out more about possible drug alternatives and the locations of participating pharmacies.




Benefit Description : Covered medications and suppliesHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

  • Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as not covered.
  • Insulin
  • Diabetes supplies including testing agents, lancet devices, alcohol swabs, glucose elevating agents, insulin delivery devices and blood glucose monitors approved by us
    • Disposable needles and syringes for the administration of covered medications
  • Self administered injectable drugs
  • Oral fertility drugs
  • Oral chemo medications -Your cost share for covered orally administered anticancer medications for the treatment of cancer will not exceed $50 per month supply
  • Growth hormone
  • Drugs for sexual dysfunction
  • Drugs or drug therapies for the treatment of gender dysphoria supported by FDA approved prescribing information and/or clinical treatment guidelines

  • Weight loss drugs

Note: Drugs to treat sexual dysfunction are limited. Contact the Plan for dosage limits. You pay the applicable drug copay up to the dosage limits, and all charges after that.

$10 for Level One drugs

$45 for Level Two drugs

$65 for Level Three drugs

$100 for Level Five drugs

25% coinsurance for Level Five drugs (specialty drugs may be limited to a 30-day supply)

Colorado:
2.5 applicable copays for a 90-day supply of prescribed maintenance
drugs, when ordered through our mail order program, or 3 times the applicable copay at participating retail pharmacies.

Illinois:
2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail-order program or participating retail pharmacies.

$10 for Level One drugs

$45 for Level Two drugs

$65 for Level Three drugs

$100 for Level Five drugs

25% coinsurance for Level Five drugs (specialty drugs may be limited to a 30-day supply)

Colorado:
2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail order program, or 3 times the applicable copay at participating retail pharmacies.

Illinois:
2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail-order program or participating retail pharmacies.

$10 for Level One drugs

$45 for Level Two drugs

$65 for Level Three drugs

$100 for Level Five drugs

25% coinsurance for Level Five drugs (specialty drugs may be limited to a 30-day supply)

Colorado:
2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through
our mail order program, or 3 times the applicable copay at participating retail pharmacies.

Illinois:
2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail-order program or participating retail pharmacies.

  • Women's contraceptive drugs and devices, including the "morning after pill"
  • Tobacco Cessation drugs

Note: Over-the-counter drugs and devices approved by the FDA require a written prescription by an approved provider. Some restrictions apply.

Nothing

Nothing

Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
  • Nonprescription medications medicines

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 38.)

All charges

All charges

All charges

Benefit Description : Preventive care medicationsHigh Option (You pay )Standard Option (You pay )Basic Option (You pay )

The following are covered:

  • Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Pre-natal vitamins for pregnant women
  • Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
  • Statin Medications for ages 40 years old or older, generic forms of atorvastatin, lovastatin and simvastatin
  • Breast cancer risk reduction medications for women with increased risk for breast cancer
  • Colonoscopy bowel preparation medications for Adults age 50 to 75
  • Prevention of Human Immunodeficiency virus (HIV) Infection – Pre Exposure Prophylaxis (HIV PreP)
  • Preventive vaccines for children and adults as recommended by the Advisory Committee on Immunization Practices (ACIP)

Note: The drugs and supplements listed above are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the- counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to 
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing

Nothing

Nothing

Not covered:

  • Drugs available without a prescription, or for which there is a non-prescription equivalent available, except as listed above
  • Drugs and supplies for cosmetic purposes
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
  • Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
  • Drugs to enhance athletic performance
  • Medical supplies such as dressings and antiseptics
  • Medications considered non-formulary on the RX5 drug list

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 38.)

All chargesAll charges

All charges




Section 5(g). Dental Benefits (High, Standard and Basic Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary
  • If you are enrolled in a Federal Employee Dental Vision Insurance Program (FEDVIP) Dental Plan, your FEHB plan will be primary payor of any Benefit payments and your FEDVIP plan is secondary to your FEHB plan. See Section 9, Coordinating benefits with Medicare and other coverage.
  • Plan dentists must provide or arrange your care.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.



Benefit Description : Accidental injury benefitHigh Option (You Pay)Standard Option (You Pay)Basic Option (You Pay)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Nothing

Nothing

Nothing

Benefit Description : Dental benefitsHigh Option (You Pay)Standard Option (You Pay)Basic Option (You Pay)
We have no other dental benefits. All charges All charges

All charges




Section 5(h). Wellness and Other Special Features (High, Standard and Basic Option)

TermDefinition

Flexible benefits option

Under the flexible benefits option: we determine the most effective way to provide services.

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefit agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Wellness Benefit

Health Assessment:

Members can benefit from completing an Health Assessment annually and using the information to guide their personal health goals; Health Assessments ask about your medical history, health status, and lifestyle to identify health risks and opportunities to improve health behavior.

Biometric Screenings:

A biometric screening is easy to complete and gives you this true picture of your health. You will not only know your numbers, but you will be able to understand them, so you can take charge of your health. It is an empowering way towards living happier and healthier and being your best.

Visit https://feds.humana.com for more information on where members can find HA and biometric screenings.

MyHumana (Humana.com)

Once you have taken your Health Assessment, check out MyHumana for resources and information to help you improve your overall health.

Wellness Reminders

You may receive messages by phone, mail or e-mail on topics such as mammograms, immunizations, and more.

Humana Pharmacy

Humana Pharmacy, a prescription home delivery service, is a wholly owned subsidiary of Humana that gives members convenience, savings, guidance, and excellent Customer Service. Humana Pharmacy is a fast and easy alternative to retail pharmacies. Depending on your location and benefits, you may be able to use Humana Pharmacy.

HumanaBeginnings®

Registered nurses offer education and support to mothers throughout pregnancy and the baby's first months.

Case ManagementNurses provide assistance for those facing a crisis or major medical procedure - includes support for parents during neonatal intensive care.
Transplant Management

This specialized team helps transplant recipients coordinate benefits, facilitate services, and follow their treatment plans.

Maximize Your Benefit (MYB)The Maximize Your Benefit (MYB) program, available to Humana members, offers guidance in helping you control the rising cost of prescription drugs with information about generics, lower cost alternatives and prescription home delivery service.

Chronic Condition Management

Programs that focus on: asthma, cancer, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, depression, chronic kidney disease, end-stage renal disease, cystic fibrosis, hypertension, mental illness, multiple sclerosis, Parkinson's disease, and other conditions. 

Personal Nurse®

Registered nurses assist those who are following treatment plans or who need continued guidance in reaching their long-term health goals.

Services for deaf and hearing impaired

Humana offers telecommunication devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing impaired. Call 1-800-432-7482 to access the service.

Humana Health Coaching

Humana’s Health Coaching offers you personalized action plans and assistance from certified health coaches. Your health coaches are specially trained experts who will educate, motivate, and support you to address: Weight management, Physical activity, Back care, Nutrition, Stress management, and Tobacco Cessation. With Humana’s health coaching model, our virtual well-being coaching partners offer digital programs that are available 24 hours a day, seven days a week throughout the year. Find out more under “Wellness” in the Health & Wellness section on www.MyHumana.com.

Employee Assistance Program (EAP)

Life, relationships, work, money, legal, family and everyday issues, all can be challenging. Sometimes you need help and guidance to come up with the answers and practical solutions. Your Employee Assistance (EAP) and Work-Life Program is here for you and your family – any day, anytime, as often as you need it. Best of all, this is a completely confidential service at no cost to you. Find out more at www.humana.com/eap or by calling 1-866-440-6556.




For more information regarding these programs, call customer service at the number on the back of your ID card.




Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract and premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact us at 1-800-4-HUMANA or feds.humana.com.

Humana’s Lifestyle Discount Program is designed to help you achieve lifelong well-being with valuable discounts and exclusive deals on popular health and wellness services. As a Humana member, you have access to this valuable program (program eligibility varies based on your service area)




TermDefinition

 

Weight loss

 

Members will receive a 50% discount off every Nutrisystem plan, seven free high-protein shakes, and free shipping on all orders. To get started, sign in to Humana.com/LifestyleDiscounts and select the link to Nutrisystem. If you prefer, call Nutrisystem at 1-866-430-8647.

Lasik

With nearly 600 locations nationwide, members may choose any in-network provider and receive these discounts: 15% off standard prices or 5% off promotional prices. Extra member value: Special set prices, free Lasik exam, affordable financing options, multiple technologies, 100% bladeless procedures, free enhancements for life on most procedures. To get started, sign in to Humana.com/LifestyleDiscounts and select the link to Lasik. If you prefer, call 1-855-645-2020.

Teeth whitening

Humana teamed up with ProSmileUSATM to offer up to 70% off teeth whitening. ProSmileUSA specializes in Hi-IntensityTM, competitive strength, professional teeth bleaching. To order a teeth whitening kit, sign in to Humana.com/LifestyleDiscounts and select the link to ProSmileUSA.

Identity monitoring and protection services

Protect yourself with identity monitoring and protection services provided by CyberScout®. This benefit provides expert support to help detect fraud, monitor credit activity, and resolve any identity-related issues. To get started or to review a complete list of services and savings, sign in to Humana.com/LifestyleDiscounts and select CyberScout (MyIDManager.com/LifestyleDiscounts).

Alternative medicine

You will get on-the-spot discounts of up to 30% when you receive services from the WholeHealth Network providers. Choose from: Chiropractic, Massage therapy, Acupuncture. It’s easy to get your savings from more than 37,000 WholeHealth Network providers. To get started, sign in to Humana.com/LifestyleDiscounts. To find a provider in your area, visit the WholeHealth Choices website at Humana.wholehealthmd.comIf you prefer, call WholeHealth at 1-866-430-8647.

Hearing aids

Humana provides you access to the TruHearing® program, which may save you 30%–60% on hearing aids. TruHearing provides hearing solutions for virtually every type of hearing loss, care from a local professional in your area, and a worry-free purchase with a 45-day trial and 3-year warranty. To learn more, visit TruHearing.com today or call 1-888-403-3937.

Vision Discount

Humana medical and dental members receive our Vision Discount program at no cost. The program offers access to more than 119,000 vision provider locations (access points) including LensCrafters, Pearle Vision, and Target Optical. To locate a network provider, members can call 1-866-995-9316 or via the following method:

Go to Humana.com > Member Resources > Find a Doctor > Vision care

Humana Individual Plans

Humana offers individual Dental and Vision products. Go to Humana.com for more information.




Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 You need prior Plan approval for certain services.

We do not cover the following:

  • Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents).
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies not medically necessary.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
  • Experimental or investigational procedures, treatments, drugs or devices. (see specifics regarding transplants)
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Services or supplies we are prohibited from covering under the Federal Law.



Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider.

If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 1-800-4HUMANA or 1-800-448-6262.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member’s name, date of birth, address, phone number and ID number
  • Name and address of the provider or facility that provided the service or supply
  • Dates you received the services or supplies
  • Diagnosis
  • Type of each service or supply
  • The charge for each service or supply
  • A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services

Note:  Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:         Humana Health Plan, Inc. 
                                                Attn: Claims Review 
                                                P.O. Box 14601 
                                                Lexington, Kentucky 40512-4601

Prescription drugs and other supplies or services

Submit your claims to:  Humana Health Plan, Inc. at the address listed above
or call us at 1-800-4HUMANA or 1-800-448-6262.

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Post-service claims procedures

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized Representative

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.




Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits (FEHB) Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing Humana Health Plan, Inc., P.O. Box 14546, Lexington KY 40512-4602 or calling 1-800-4HUMANA or 1-800-448-6262.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription

1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Humana Health Plan, Inc., P.O. Box 14546, Lexington, KY 40512-4602; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

  • 90 days after the date of our letter upholding our initial decision; or
  • 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
  • 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
  • Copies of all letters you sent to us about the claim;
  • Copies of all letters we sent to you about the claim; and
  • Your daytime phone number and the best time to call.
  • Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 1-800-523-0023. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 3 at 1-(202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage or coverage for injuries

You must tell us if you or a covered family member has coverage under any other health plan. You must also tell us if any treatment you receive may be covered by workers’ compensation or any coverage that pays for injuries regardless of who is at-fault for the injury. Other health plans and injury coverage may be considered “double coverage.” 

As a condition of receiving benefits under this plan, you agree to cooperate with our efforts to determine whether other coverage may exist and to assist us and our agents as needed. Failure to cooperate with our efforts may result in delay or denial of benefits under this plan. When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at https://feds.humana.com.

  • If you are a dependent or annuitant on this Plan and you have group health insurance through your employer, your employer is the primary payor and we are the secondary payor.
  • When you sustain injuries and are entitled to the payment of healthcare expenses under automobile, property, home owners insurance or any other coverage that pays regardless of fault, that insurance coverage is the primary payor and we are the secondary payor.

When we are the primary payor, we will pay the benefits described in this brochure. When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

In the event that we provide benefits for treatment that should have been covered by a primary payor, we shall have the right to be repaid from whoever has received any overpayment from us to the extent that we have provided double coverage.

TRICARE and CHAMPVA

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Workers’ Compensation

We do not cover services that:

  • You (or a covered family member) need because of a workplace-related illness or injury that should be covered under any other workers’ compensation policy or that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or

OWCP or a workers’ compensation carrier pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP pays its maximum benefits for your treatment, we will cover your care. You must use our providers.

Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When others are responsible for injuries

By accepting benefits under this plan you agree to the following conditions and limitations on the nature of benefits or benefit payments when another person causes an injury or illness or when you are entitled to recover from any other insurance or source of funds that may be available to pay for the injury or illness. 

Humana is entitled to recover the full value of the benefits we have paid or provided in connection with your injury or illness. However, when benefits are otherwise provided by this plan we will cover the cost of treatment that exceeds the amount of the payment you received. You and all covered persons agree to promptly notify us that you have asked anyone other than us to make payment for your injuries and to fully cooperate with our efforts to secure our recovery rights. You and your representative also agree to obtain our consent before releasing any party from liability for payment of medical expenses and before disbursing any funds paid by other parties.

When benefits are provided under the Plan in relation to the illness or injury, Humana may, at its option:

  • Subrogate, that is, take over your right to pursue recovery from any other parties, insurance carriers or sources of funds that you may have a right to pursue; or
  • Enforce a right to reimbursement from any payment(s) you or your representative may obtain from other parties, settlements or insurance coverage.

Our right to recover the full value of the benefits we have paid or provided for shall take first priority (before any of the rights of any other parties are honored) and are not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. The amount we are entitled to recovery is not subject to reduction based on attorney fees or costs under the “common fund” or similar rules and is fully enforceable regardless of whether you are “made whole” or compensated for the full amount of damages you may have incurred.

Our recovery rights shall apply only to the extent of the full value of benefits provided for the injury or illness. We will provide benefits to cover the cost of treatment that exceeds amounts that are recoverable other insurance coverage or sources of funds.

If you, a covered person or your representative fails to cooperate with the enforcement of our recovery rights we may delay or deny future benefits until cooperation is provided or we are reimbursed.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials. This plan does not cover these costs.

When you have Medicare

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be authorized by your Plan primary care physician

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 1-800-4HUMANA or contact us at our website: https://feds.humana.com.

Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B. 

Benefit Description: Deductible
High Option You pay without Medicare: $0
Standard Option You pay without Medicare: $0
Basic Option You pay without Medicare: $0
High Option You pay with Medicare Part A and B: $0
Standard Option You pay with Medicare Part A and B: $0
Basic Option You pay with Medicare Part A and B: $0

Benefit Description: Out of Pocket Maximum
High Option You pay without Medicare: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Standard Option You pay without Medicare: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Basic Option You pay without Medicare: $8,150 Self Only/$16,300 Self Plus One or Self and Family
High Option You pay with Medicare Part A and B: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Standard Option You pay with Medicare Part A and B: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Basic Option You pay with Medicare Part A and B: $8,150 Self Only/$16,300 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
High Option You pay without Medicare: N/A
Standard Option You pay without Medicare: N/A
Basic Option You pay without Medicare: N/A
High Option You pay with Medicare Part A and B: N/A
Standard Option You pay with Medicare Part A and B: N/A
Basic Option You pay with Medicare Part A and B: N/A

Benefit Description: Primary Care Physician
High Option You pay without Medicare: $20
Standard Option You pay without Medicare: $35
Basic Option You pay without Medicare: $50
High Option You pay with Medicare Part A and B: $20
Standard Option You pay with Medicare Part A and B: $35
Basic Option You pay with Medicare Part A and B: $50

Benefit Description: Specialist
High Option You pay without Medicare: $40
Standard Option You pay without Medicare: $55
Basic Option You pay without Medicare: $70
High Option You pay with Medicare Part A and B: $40
Standard Option You pay with Medicare Part A and B: $55
Basic Option You pay with Medicare Part A and B: $70

Benefit Description: Inpatient Hospital
High Option You pay without Medicare: $400 copay per day for the first three (3) days per admission
Standard Option You pay without Medicare: $600 copay per day for the first three (3) days per admission
Basic Option You pay without Medicare: $900 copay per day for the first five (5) days per admission
High Option You pay with Medicare Part A and B: $400 copay per day for the first three (3) days per admission
Standard Option You pay with Medicare Part A and B: $600 copay per day for the first three (3) days per admission
Basic Option You pay with Medicare Part A and B: $900 copay per day for the first five (5) days per admission

Benefit Description: Outpatient Hospital
High Option You pay without Medicare: $400
Standard Option You pay without Medicare: $500
Basic Option You pay without Medicare: $700
High Option You pay with Medicare Part A and B: $400
Standard Option You pay with Medicare Part A and B: $500
Basic Option You pay with Medicare Part A and B: $700

Benefit Description: Incentives offered
High Option You pay without Medicare: NA
Standard Option You pay without Medicare: NA
Basic Option You pay without Medicare: NA
High Option You pay with Medicare Part A and B: NA
Standard Option You pay with Medicare Part A and B: NA
Basic Option You pay with Medicare Part A and B: NA

You can find more information about how our plan coordinates benefits with Medicare by calling 1-800-4HUMANA or visit the Medicare website at https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance.

Tell us about your Medicare coverage

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

Medicare Advantage
(Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE 1-800-633-4227, (TTY 1-877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

Medicare prescription drug coverage (Part D)

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

  • Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy
  • Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
  • Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. This plan does not cover these costs.

Coinsurance

See Section 4, page 22.

Copayment

See Section 4, page 22.

Cost-sharing

See Section 4, page 22.

Covered services Care we provide benefits for, as described in this brochure.

Custodial care

Services provided to you such as assistance with dressing, bathing, preparation and feeding of special diets, walking, supervision of medication which is ordinarily self-administered, getting in and out of bed, and maintaining continence, which are not likely to improve your condition. Custodial care that lasts 90 days or more is sometimes known as long term care.

Durable Medical Equipment (DME)

Equipment recognized as such by Medicare Part B, that meets all of the following criteria:

  • it can stand repeated use; and
  • it is primarily and customarily used to serve a medical purpose rather than being primarily for comfort or convenience; and
  • it is usually not useful to a person in the absence of sickness or injury; and
  • it is appropriate for home use; and
  • it is related to the patient’s physical disorder, and the equipment must be used in the member’s home.

Experimental or investigational services

A drug, biological product, device, medical treatment, or procedure is determined to be experimental or investigational if reliable evidence shows it meets one of the following criteria:

  • When applied to the circumstances of a particular patient is the subject of ongoing phase I, II or III clinical trials, or
  • When applied to the circumstances of a particular patient is under study with written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional alternatives, or
  • Is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by the USFDA or Department of Health and Human Services, or
  • Is not generally accepted by the medical community.

Reliable evidence means, but is not limited to, published reports and articles in authoritative medical scientific literature or regulations and other official actions and publications issued by the USFDA or the Department of Health and Human Services.

Healthcare professional

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medical necessity

The determination as to whether a medical service is required to treat a condition, illness, or injury. In order to meet the standard of medical necessity the service must be consistent with symptoms, diagnosis, or treatment; consistent with good medical practice; and the most appropriate level of service that can be safely provided.

Morbid obesity

Excess body weight in comparison to set standards. Obesity refers specifically to having an abnormal proportion of body fat. The primary classification of overweight and obesity is based on the assessment of Body Mass Index (BMI).

Oral surgery Procedures to correct diseases, injuries and defects of the jaw and mouth structures.
Participating provider A hospital, physician, or any other health services provider who has been designated to provide services to covered members under this plan.

Plan Allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance using Humana's fee schedule for similar providers in your service area.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Post-service claims

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Pre-service claimsThose claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

Reimbursement

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Service area The geographic area where the participating provider services are available to covered members.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.
Transplant Services for pre-transplant; the transplant including any chemotherapy, associated services and post-discharge services, and treatment of complications after transplant.

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will evaluate whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at the number printed on your Humana ID card. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We Us and We refer to Humana Health Plan, Inc.
You You refers to the enrollee and each covered family member.



Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.



Index Entry
(Page numbers solely appear in the printed brochure)



Summary of Benefits for High Option of Humana Health Plan, Inc. - Chicago, Central and Northwestern Illinois, Denver and Colorado Springs - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://feds.humana.com
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



High Option BenefitsYou payPage

Medical services provided by physicians:

  • Diagnostic and treatment services provided in the office

 

$20 copay PCP; $40 copay specialist


27

Services provided by a hospital:

  • Inpatient


$400 copay per day for the first three (3) days per admission

48

Services provided by a hospital:

  • Outpatient - surgical
  • Outpatient - other services such as MRI, MRA, CT, PET, SPECT
  • Outpatient - other non-surgical care

 

  • $400 copay per surgery
  • $200 copay per visit
  • Nothing

49

Emergency benefits:

  • In and out-of-area (emergency room)
  • At a doctor’s office
  • In and out-of-area (urgent care)


$200 copay per visit
$20 copay PCP; $40 copay specialist
$40 copay per visit

53

Mental health and substance use disorder treatment

Regular cost-sharing

55

Prescription drugs:

  • Level One drugs
  • Level Two drugs
  • Level Three drugs
  • Level Four drugs
  • Level Five drugs (Specialty drugs)
  • Maintenance drugs (90-day supply) when ordered through our mail-order program or participating retail pharmacies

 

  • $10 copay
  • $45 copay
  • $65 copay
  • $100 copay
  • 25% coinsurance
  • Maintenance drugs - 2.5 applicable copays

59

Dental care:  Accidental injury benefit only

Nothing

63

Vision care:  Eye refractions

$40 copay per visit

36

Special features:  Wellness Benefit, Personal Nurse; MyHumana; HumanaBeginnings; Chronic Condition management; Transplant management; Case management; EAP; Humana Health Coaching; TDD and TTY phone lines

64

Protection against catastrophic medical and pharmacy costs (out-of-pocket maximum).

Nothing after $8,150 for Self Only or $16,300 for Self Plus One or Self and Family enrollment per year.

22




Summary of Benefits for Standard Option of Humana Health Plan, Inc. - Chicago, Central and Northwestern Illinois, Denver and Colorado Springs - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://feds.humana.com
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



Standard Option BenefitsYou PayPage

Medical services provided by physicians:

  • Diagnostic and treatment services provided in the office

$35 copay PCP; $55 copay specialist

27

Services provided by a hospital:

  • Inpatient

 
$600 copay per day for the first three (3) days per admission


48

Services provided by a hospital:

  • Outpatient - surgical
  • Outpatient - other services such as MRI, MRA, CT, PET, SPECT
  • Outpatient - other non-surgical care

 

  • $500 copay per visit
  • $250 copay per visit
  • Nothing

49

Emergency benefits:

  • In and out-of-area (emergency room)
  • At a doctor’s office
  • In and out-of-area (urgent care)


$250 copay per visit
$35 copay PCP; $55 copay specialist
$55 copay per visit


53

Mental health and substance use disorder treatment

Regular cost-sharing

55

Prescription drugs:

  • Level One drugs
  • Level Two drugs
  • Level Three drugs
  • Level Four drugs
  • Level Five drugs (Specialty drugs)
  • Maintenance drugs (90-day supply) when ordered through our mail-order program or participating retail pharmacies

 

  • $10 copay
  • $45 copay
  • $65 copay
  • $100 copay
  • 25% coinsurance
  • Maintenance drugs - 2.5 applicable copays

59

Dental care: Accidental injury benefit only

Nothing

63

Vision care: Eye refractions

$55 copay per visit

35

Special features: Wellness Benefit, Personal Nurse; MyHumana; HumanaBeginnings; Chronic Condition management; Transplant management; Case management; EAP; Humana Health Coaching; TDD and TTY phone lines

64

Protection against catastrophic medical and pharmacy costs (out-of-pocket maximum).

Nothing after $8,150 for Self Only or $16,300 for Self Plus One or Self and Family enrollment per year.

22




Summary of Benefits for Basic Option of Humana Health Plan, Inc. - Chicago, Central and Northwestern Illinois, Denver and Colorado Springs - 2022

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://feds.humana.com
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



Basic Option BenefitYou PayPage

Medical services provided by physicians:

  • Diagnostic and treatment services provided in the office

 

$50 copay PCP; $70 copay specialist


27

Services provided by a hospital:

  • Inpatient


$900 copay per day for the first five (5) days per admission


48

Services provided by a hospital:

  • Outpatient - surgical
  • Outpatient - other services such as MRI, MRA, CT, PET, SPECT
  • Outpatient - other non-surgical care

 

  • $700 copay per visit
  • $300 copay per visit
  • Nothing

49

Emergency benefits:

  • In and out-of area (emergency room)
  • At a doctor’s office
  • In and out-of area (urgent care)


$325 copay per visit
$50 copay PCP; $70 copay specialist
$70 copay per visit


53

Mental health and substance use disorder treatment

Regular cost-sharing

55

Prescription drugs:

  • Level One drugs
  • Level Two drugs
  • Level Three drugs
  • Level Four drugs
  • Level Five drugs (Specialty drugs)
  • Maintenance drugs (90-day supply) when ordered thru our mail-order program

 

  • $10 copay
  • $45 copay
  • $65 copay
  • $100 copay
  • 25% coinsurance
  • Maintenance drugs - 2.5 applicable copays

59

Dental care: Accidental injury benefit only

Nothing

63

Vision care: Eye refractions

$70 copay per visit

35

Special features: Wellness Benefit; Personal Nurse; MyHumana; HumanaBeginnings; Chronic Condition management; Transplant management; Case management; EAP; Humana Health Coaching; TDD and TTY phone lines

64

Protection against catastrophic medical and pharmacy costs (out-of-pocket maximum).

Nothing after $8,150 for Self Only or $16,300 for Self Plus One or Self and Family enrollment per year.

22




2022 Rate Information for Humana Health Plan, Inc.

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Colorado: Colorado Springs
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self OnlyNR1$244.86$203.20$530.53$440.27
High Option Self Plus OneNR3$524.63$438.70$1,136.70$950.52
High Option Self and FamilyNR2$574.13$434.00$1,243.95$940.33
Standard Option Self OnlyNR4$230.57$76.85$499.56$166.52
Standard Option Self Plus OneNR6$495.72$165.24$1,074.06$358.02
Standard Option Self and FamilyNR5$518.79$172.93$1,124.05$374.68
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Basic Option Self OnlyR21$209.73$69.91$454.42$151.47
Basic Option Self Plus OneR23$450.91$150.30$976.97$325.65
Basic Option Self and FamilyR22$471.89$157.29$1,022.42$340.80
Colorado: Denver
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self OnlyNT1$244.86$159.12$530.53$344.76
High Option Self Plus OneNT3$524.63$343.93$1,136.70$745.18
High Option Self and FamilyNT2$574.13$334.84$1,243.95$725.49
Standard Option Self OnlyNT4$204.32$68.11$442.70$147.57
Standard Option Self Plus OneNT6$439.31$146.44$951.85$317.28
Standard Option Self and FamilyNT5$459.74$153.24$996.09$332.03
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Basic Option Self OnlyRZ1$179.63$59.88$389.21$129.73
Basic Option Self Plus OneRZ3$386.21$128.74$836.80$278.93
Basic Option Self and FamilyRZ2$404.16$134.72$875.68$291.89
Illinois: Central and Northwestern
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self Only9F1$244.86$732.05$530.53$1,586.11
High Option Self Plus One9F3$524.63$1,575.71$1,136.70$3,414.04
High Option Self and Family9F2$574.13$1,623.92$1,243.95$3,518.49
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Standard Option Self OnlyAB4$244.86$423.20$530.53$916.93
Standard Option Self Plus OneAB6$524.63$911.73$1,136.70$1,975.41
Standard Option Self and FamilyAB5$574.13$929.03$1,243.95$2,012.90
Basic Option Self OnlyAB1$244.86$145.57$530.53$315.40
Basic Option Self Plus OneAB3$524.63$314.82$1,136.70$682.11
Basic Option Self and FamilyAB2$574.13$304.36$1,243.95$659.45
Illinois: Chicago
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self Only751$244.86$402.79$530.53$872.71
High Option Self Plus One753$524.63$867.82$1,136.70$1,880.28
High Option Self and Family752$574.13$883.08$1,243.95$1,913.34
Standard Option Self Only754$244.86$242.43$530.53$525.27
Standard Option Self Plus One756$524.63$523.06$1,136.70$1,133.30
Standard Option Self and Family755$574.13$522.28$1,243.95$1,131.61
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
Basic Option Self OnlyRW1$244.86$142.60$530.53$308.97
Basic Option Self Plus OneRW3$524.63$308.41$1,136.70$668.22
Basic Option Self and FamilyRW2$574.13$297.66$1,243.95$644.93