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.
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 received. 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.
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 Member Services.
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.
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.
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.
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.
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.
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.