Using a healthcare plan

To get the most from any healthcare plan, you need to know how to use it. The links below explain the basics of using a healthcare plan. You also can find meanings to common healthcare terms.

Note: The following information applies to commercial health plan members only. Medicare members may refer to their Evidence of Coverage booklet for plan information, or call Member Service at the number shown on their Humana ID card for assistance.

How to get help in another language

Humana has free help for members who don't speak English or need extra help. Call the Customer Service phone number listed on your Humana ID card. We have free help for you in any language you need.

Understanding your plan

Here's how you can quickly get information about your coverage:

Online: To get your plan details anytime:

1. Log in to MyHumana
2. Select "My Plans & Coverage"
3. Select the "Details" button under the name of your plan
4. Choose the "Plan Benefit Detail" tab under "Plans and Coverage Detail"

To print a copy– If you want to print your coverage details, just click "Download PDF." You'll see pages come up on your screen that you can print out.
The "Coverage Details" booklet tells about your plan, what's covered, and what's not. It also tells you about any limits on your coverage. You also can call the Customer Service number on the back of your ID card if you have questions.

Understanding your costs

Here are some basic healthcare words and what they mean, as well as examples of costs. Please look at your benefit summary and coverage booklet for the details of your plan.

Claim

A claim is information your providers (doctors, hospitals, and others) send to Humana asking to be paid for their services. This bill has special codes for each service you got. The bill also has the doctor's normal charge for each service. When Humana gets this bill, it becomes a claim. After Humana handles your claim, you'll get an Explanation of Benefits (EOB) showing what we paid and what you owe. Sometimes you don't owe anything. Some members get a Claim Receipt instead of an EOB. Either way, you'll know just how we handled your medical services.

Claim payment

Usually, we handle your provider claims without you having to do anything. But sometimes you have to pay the provider yourself. Then you need to ask us to send you back the money we owe you for this service. Here's how to get your money back for a service you paid for yourself. Just send the provider's bill showing the services and a copy of the member's Humana ID card to the claims address on the back of the ID card. Make sure the bill shows the patient's name and Humana ID number. If you have questions about your claims, call Customer Service.

Coinsurance

Coinsurance is a set amount (a percentage) of the cost you must pay for your medical care or prescription drugs. For example, your plan may pay 80 percent of the cost. Then you pay 20 percent.

Copayment

A copayment is the amount you pay when you receive medical care or a prescription drug. The copayment is different depending on your plan and the services you get. For example, you may have a $40 copayment for a doctor's office visit. And your plan would pay for the rest.

Deductible

Your deductible is the amount you pay toward certain medical expenses. You pay this amount before your plan starts paying any of the costs. Usually your copayments are dollars you pay in addition to your deductible. For example, a deductible may be $500 for single coverage and $1,000 for a family plan. Not all plans have deductibles. Check your plan materials to be sure.

Out-of-pocket maximum

Most Humana plans help protect you with an out-of-pocket limit. This limit is the most you'll pay for medical care in a plan year. As you use medical services, much of what you spend is added up to help "pay off" your out-of-pocket limit. Once you reach the limit, your plan pays 100 percent of covered services. You continue to pay copayments if your plan has them. Not all plans have an out-of-pocket maximum. Check your plan materials to be sure.

Payment

You can pay for your part of the cost in one of several ways. Payment depends on what your provider takes – cash, check, or credit card. If you have a Humana spending account, you may want to use your HumanaAccess® Visa® Debit Card.

Provider

A provider is any person or place that gives you medical care. Providers can be hospitals, clinics, and doctors. You can find a provider in your network using the Provider Search on this Website or using Humana's MyChoice ToolsSM. Not all plans have a network. Check your plan materials to be sure.

Getting medical care

The right care, when you need it

When it's time to use your benefits, you should know how to find the best care. You'll also want to find the best price. Using the right provider for your needs can save you time and money. Here are some places you can go, depending on the care you need:

Retail clinic

You can often find retail clinics in supermarkets or drug stores. They are open the same hours as the store. You usually don't need an appointment for low-cost treatment of minor problems.

Doctor

For normal care, go to your family doctor. Your doctor knows your health history and keeps it on file. Your doctor also is the best person to see for your exams each year.

Immediate care center

Immediate care centers are a smart choice when your doctor's office is closed or you can't get an appointment right away. If you have a minor injury or illness, think about using one of these centers. If your doctor's office is closed, an immediate care center is a good choice because:

  • They usually don't require appointments
  • They're open later than most doctors' offices
  • They provide faster care at a lower price

Emergency room

If you think you have a serious medical problem—like a stroke or heart attack—please play it safe. Go to the nearest emergency room (ER). Get emergency care right away if you have any of these concerns:

  • Chest pain
  • Trouble breathing
  • Poisoning
  • Bleeding or vomiting that won't stop
  • Major burns, cuts, or breaks

You don't need anyone's OK during an emergency. Just go to the closest ER!

You can search "Hospital" under Humana's online Provider Search to find a hospital emergency room in Humana's network. Then put the information where it's easy to find. You may want to put it by your phone or refrigerator. That way, if you do have a medical emergency, you may still be able to use an in-network facility and save money.

Outpatient care centers and surgery centers

Outpatient care centers can take care of many outpatient services, including some tests and surgery. Places that handle surgery outside of a hospital are called "surgery centers." If your doctor wants you to have tests or surgery, ask whether you can go to an outpatient care or surgery center. They can be easier to use, and they can cost less than going to a hospital.

Care in the hospital

You may have to stay in the hospital for some medical problems. Remember, this care is usually very expensive. Hospital care costs you a lot more than other choices. To save money, you may want to see if you can use an outpatient center or immediate care center before you consider going into a hospital. And be sure to choose a hospital in your plan's network, if your plan has a network. Talk with your doctor before you make any decisions about hospital care.

Mental health

Please call the Customer Service number on the back of your ID card before you look for a mental health provider on this Website. If you have health coverage through your employer, your employer may use a different network of providers. Our Customer Care Specialists will help you find the right providers for your plan.

Care away from home

When you're traveling, you can save money by using providers in Humana's network. When you're away from home, call the number on the back of your ID card to find an in-network provider. Or, before you go, log in to MyHumana and use the "Provider Search" box to look for doctors and hospitals in the area you're going to visit. Your network may not let you use providers who are not in your plan's area. If you need emergency care while traveling, go to the nearest urgent care center or emergency room, depending on your problem. Your plan covers true medical emergencies no matter what provider you use.

If you're not sure where to get medical care, call the HumanaFirst® Nurse Advice Line. You can call anytime, 24 hours a day, at 1-800-622-9529. Ask your employer if this service is part of your plan.

Finding a provider in your network

What is a network?

A network is a group of providers in a certain area that work with Humana. These providers agree to give you healthcare services at lower costs. When you visit in-network providers, you usually pay less for services. And the provider takes care of your claims for you. When you go to a provider who is not in your network, you pay more for your care. You also may have to file your own claims. And sometimes the services you get from out-of-network providers may not be covered—except in an emergency. Not all plans have a network. Check your plan materials to be sure.

Choose a family doctor from Humana's in-network doctors

Besides a family doctor, many of us see a specialist from time to time. Here's a good way to keep track of all your medical care. Choose a family doctor or primary care physician to coordinate your care. That way you can be sure all of your tests, medicines, and any specialty care go through one trusted person. This could save you from getting the same test twice or using two medicines together that could hurt your health. Choosing and working with a family doctor can save you time and money, as well as prevent health problems.

Remember, with some plans, you must choose a primary care physician to oversee your medical care. Check your plan documents to be sure.

Physician Finder Plus

Need to find a healthcare provider in your network who's also close to home? Want to find a doctor who fits your needs? Having trouble finding an in-network specialist? Then you need Physician Finder Plus.

Just log in to MyHumana and choose "Locate a doctor or other healthcare provider" under the "Doctors/Rx Tools" button. Then click on the provider you need under "Provider Search." You can find a provider by:
Location – You can choose someone near your home or in a specific county.
Provider type – Get the provider or specialty you need.
Name – You can look up a specific provider by name.
You'll get your search results by last name. And you'll get details like address, phone number, and office hours. You'll also get driving directions to a provider's office. If you need a doctor who speaks another language, you can find that out, too.

Getting the most from your drug benefit

If your plan includes drug benefits, check out the Pharmacy Tools section of *My*Humana for helpful information on your specific benefits. This includes information on finding an in-network pharmacy, getting your prescription drugs by mail-order, information on generic drugs and lower-cost alternative drugs, and Humana's Drug List. Humana's Drug List gives information on coverage for each drug, and any special requirements for certain drugs to be covered.

Special Health Programs

Humana has special programs to help you if you have complicated medical conditions or certain chronic conditions. Our case management program offers supportive services to members with complicated medical conditions, or those who have been hospitalized. A Humana nurse helps you navigate the health care system and assists in coordinating services. Other programs help people manage health conditions like diabetes, heart failure, COPD and other illnesses.

If you would like more information about these special health programs you may call the Health Planning and Support team at 1-800-491-4164.

Member Rights and Responsibilities

As a Humana plan member, you have certain rights and responsibilities when being treated by Humana-contracted physicians. The rights and responsibilities statement reminds members and physicians of their complementary roles in maintaining a productive relationship.

View Member Rights

Quality Improvement (QI) Program

Humana's quality improvement program includes clinical care, preventive care and member services. Click here to view Humana's Quality Improvement Progress Report for information about Humana's quality improvement program and progress toward meeting goals.

Members may also obtain a written quality improvement (QI) program description by calling 1-800-4-HUMANA (1-800-448-6262), or provide input into the QI Program by writing to:

Humana Quality Management Department
321 West Main, WFP 20
Louisville, KY 40202

Technology Assessment

Humana's technology assessment department conducts medical technology evaluations to confirm whether medical devices or procedures approved by the U.S. Food and Drug Administration (FDA) should be formally adopted. The Humana review assesses and confirms the device or procedure has been studied and found to be effective and safe as reported in peer-reviewed medical literature or recommended by the recognized medical specialty societies in the United States. The FDA approval is based on reasonable levels of safety, but does not confirm that a procedure is necessarily a best medical practice. The Humana assessment helps the organization make proactive decisions on coverage for our members, so the care they are getting is clinically sound and in their best interest.

Utilization Management

At Humana, a process called utilization management (UM) is used to determine whether a service or treatment is covered and appropriate for payment under your benefit plan. Humana does not reward or provide financial incentives to doctors, other individuals or Humana employees for denying coverage or encouraging under use of services. In fact, Humana works with your doctors and other providers to help you get the most appropriate care for your medical condition.

If you have questions or concerns related to utilization management, staff are available at least eight hours a day during normal business hours.

Humana has free language interpreter services available to answer questions related to Utilization Management from non-English speaking members. TTY/TDD users should call 1-800-833-3301 or 711.

If you ever disagree with a coverage decision, you can ask to have your case reviewed by an independent panel. Just call Customer Service at the number on your ID card to find out how.

How to file a complaint

If you have a problem with Humana or one of our network providers or are unhappy with the care or services you receive, please call Member Services at the toll-free number on the back of your member ID card. We will try to resolve any problem you might have over the phone. Member Services can also provide you with information on submitting a formal written complaint.

Appealing a decision

Contact Member Services to discuss any questions or concerns you may have about your health plan coverage. Most info or problems are taken care of informally. However, if you are still unhappy with how your case was handled, you can file a formal appeal. Your appeal can be about medical or non-medical parts of your care. Normally most appeals are filed when we've denied or reduced a service or claim payment. Member Services can explain your appeal rights and how to submit an appeal. You also can have this information sent to you in writing.