Humana One HSA-Compatible Plan (with 80% Coverage) - Indiana
INDIANA Plan 49, Option 201
Lifetime Maximum Benefit
$5,000,000 per covered person (combined network and non-network)
Calendar-year Deductible1,2
$1,500 individual / $3,000 family3
$3,000 individual / $6,000 family
3
$2,000 individual / $4,000 family3
$4,000 individual / $8,000 family
3
$2,600 individual / $5,150 family3
$5,200 individual / $10,300 family
3
Out-of-Pocket Maximum (including deductible)1,2,3
$3,500 individual / $7,000 family
$11,000 individual / $22,000 family
$4,000 individual / $8,000 family
$12,000 individual / $24,000 family
$4,600 individual / $9,150 family
$13,200 individual / $26,300 family
• Routine annual physical exam
20% not subject to deductible
Not covered
• Routine immunizations (to age 18)
"
"
• Routine Pap smears and PSA5
"
"
• Routine Mammograms5
"
"
• Routine lab, pathology and X-ray
20% after deductible
Not covered
• Office visits (includes diagnostic lab and X-ray)
20% after deductible
40% after deductible
• Allergy testing, injections and serum
"
"
• Outpatient services (includes surgery)
"
"
Hospital Services
20% after deductible
40% after deductible
• Outpatient surgery - facility
"
"
• Outpatient non-surgical
"
"
• Emergency room (including physician visits)
"
"
• Benefit for each prescription or refill (up to 30-day supply)
20% after deductible
40% after deductible
• Mail order (90-day supply)
"
"
• Skilled nursing facility (up to 30 days per calendar year)7
20% after deductible
40% after deductible
• Home health care (up to 60 visits per calendar year)7
"
"
• Durable medical equipment7
"
"
• Complications of pregnancy and sick baby services9
"
"
• Transplant services (organ)7
20% after deductible (when services are performed at a National Transplant Network provider)
40% after deductible (subject to separate out-of-pocket maximum of $35,000 per calendar year)
Alcohol and Chemical Dependence
•
Inpatient care and Outpatient care (Combined $2500 per calendar year maximum benefit, with Outpatient care not to exceed $500 of the $2,500 per calendar year maximum benefit.)50% after deductible
50% after deductible
• Inpatient
20% after deductible
40% after deductible
Humana One Term Life
Available as option - additional cost
1
When you obtain care from nonparticipating providers, 50 percent of your payment toward the deductible is credited to the deductible for participating providers. Once you meet your single or family (if applicable) deductible and out-of-pocket expense
limits, the plan pays 100 percent for covered services.
2
The medical out-of-pocket maximum does not apply to transplant services or mental health services from nonparticipating providers.
3
For other than single coverage, the family deductible applies. The single deductible applies to single coverage policies only.
4
$300 of covered expenses per person per calendar year, subject to applicable coinsurance.
5
Age and/or frequency limits apply.
6
If a nonparticipating pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement.
7
Prior authorization required in order to be eligible for these benefits.
8
Counseling for hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
9
Routine pregnancy expense is not covered and such coverage is not available as an optional benefit.
Payments
Participating providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other co-payments. Plan benefits paid to nonparticipating providers are based on maximum
allowable fees, as defined in your policy.
Nonparticipating providers may balance bill you for charges in excess of the maximum allowable fee. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or co-payment.
Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible.
Participating Providers
Participating primary care and specialist physicians and other providers in Humana’s networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of
medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you.
This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms
and conditions of the policy will govern.
