Using a health insurance plan
To get the most from any health plan, you need to know how to use it. The information below explains the basics of using a health plan. You can also find meanings to common healthcare terms.
Note: The following information applies only to health insurance you get through your employer or individual health insurance you purchase directly, including Humana plans purchased on the federal or state healthcare Marketplace (for example, healthcare.gov).This information does not apply to Medicare or Medicaid members, who should refer to their Evidence of Coverage booklet or Member Handbook for plan information. Whenever you have questions, you may call Member Service at the number shown on your Humana ID card for plan information or assistance.
How to get help in another language or other communication assistance
Humana has free language interpreter services for members who don't speak English or need extra help. Humana also provides oral interpretation at no cost, as well as sign language and alternative formats such as Braille, Audio, and Large Print. More information is available at this link: Accessibility Resources, or you may call the Member Service phone number listed on your Humana ID card.
Understanding your plan
Here's how you can quickly get information about your coverage:
Get your plan details online anytime:
- Go to Humana.com and log-in to your personal account. If you have never logged in before, it is simple – just click on “Register now as a new user.”
- Once you are logged in, select "Coverage, Claims & Spending" from the menu bar at the top of the screen.
- Select the "View Coverage" link under the name of your health plan.
- Click on the “Coverage Details” link. You can print out the coverage details document if you want, or refer to it online any time.
The coverage details document tells about your health plan, what's covered, and what's not. It also tells you about any limits on your coverage. You can also call the Member Service number on the back of your ID card any time if you have questions.
Understanding your costs
Here are some basic healthcare terms and what they mean, as well as examples of costs. For the details of your specific plan, please review your coverage details online as described above, or call Member Service at the toll-free number on your Humana ID card. ClaimA claim is a request for payment, or bill, your providers (doctors, hospitals, and others) send to Humana for services they provided to you. 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. Claim paymentUsually, when you use a provider in your Humana network, the provider will submit the claim to Humana on your behalf. But sometimes you may have to pay the provider yourself. Then you need to ask us to send you back the money we owe you for services covered by your health plan. 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 your Humana ID card. Make sure the bill shows the patient's name and Humana ID number. If you have questions about your claims, call Member Service. CoinsuranceAfter you pay any plan deductibles, you may still be responsible for a percentage of the cost of services you received. This is called coinsurance. For instance, if your health plan pays 70% of the cost, your coinsurance payment is the remaining 30%. CopaymentA copayment, or co-pay, is the flat amount you pay to a healthcare provider or pharmacy at the time of service. Copayments vary depending on your plan and the services you receive. For example, you may have a $40 copayment for a doctor's office visit. DeductibleYour deductible is the amount you pay toward certain medical expenses before your insurance plan starts paying any of the costs. Your plan may have a deductible for medical care and a separate deductible for prescription drugs. Also, if your plan has benefits for care outside of your Humana provider network, the plan will have separate deductibles for in-network care and out-of-network care. Check your plan coverage details to see what deductibles you have. Usually, if your plan requires copayments, those are dollars you pay in addition to your deductible.Even if your plan does not begin paying any of your medical expenses until you have met a deductible, this does not mean you are paying full price. You receive Humana’s negotiated rate with network providers for services you must pay for until your deductible has been reached. Here’s an example: John has not yet reached his $3,000 health plan deductible this year – he has only had about $400 in medical expenses so far. John goes to a Humana network doctor for an office visit due to illness, and the doctor submits a claim to Humana for $95. Humana has a contract with the doctor that includes a negotiated rate of $60 for office visits. John will receive an Explanation of Benefits (EOB) from Humana indicating he owes the doctor the $60 negotiated rate, instead of the full $95 bill. The doctor must accept the negotiated rate as payment in full. Out-of-pocket MaximumMost Humana plans help protect you with an out-of-pocket maximum. This amount is the most you'll pay for covered medical care in a plan year. As you use medical services, the part of the cost you pay (for example, copayments and deductibles) is added up throughout the plan year. Once the total amount you’ve paid reaches the out-of-pocket maximum, your plan pays 100 percent of covered services. Check your plan materials for details. Payment to ProvidersYou can pay for your part of the cost of medical care or prescription drugs in one of several ways. Payment depends on what your provider accepts – cash, check, or credit card. If you have a Health Savings Account (HSA), you can use it to make payments to providers. ProviderA provider is a person or place that gives you medical care. Providers include doctors, hospitals, retail clinics, urgent care centers, and other healthcare professionals and facilities. You can find a provider in your network using the “Find a Doctor” link on this Website.
Getting medical care
This material is provided for informational use only and should not be construed as medical advice or used in place of consulting a licensed medical professional. You should consult with your doctor to determine what is right for you. The right care, when you need itWith your Humana health plan, you have access to healthcare services at doctors, retail clinics, urgent care centers and hospitals in your plan’s network. Seeing these network providers may save you time and money when you need care. Here are some places you can go, depending on the care you need: DoctorYour primary care doctor is always your first choice, unless it’s an emergency. In fact, visiting your doctor for a preventive care checkup, covered by most plans at no extra cost, gives your doctor a chance to get to know you so he or she can be a true partner in helping you achieve lifelong well-being. Retail clinicYou can often find retail clinics in supermarkets or drug stores. They are usually open the same hours as the store. You usually don't need an appointment for low-cost treatment of minor problems. Check your provider directory to see which retail clinics are available in your plan’s network. Urgent care centerAn urgent care center or retail clinic is a great choice if your doctor isn’t available and you need care right away for something like the flu, infections, minor burns or sprains. You don’t need to schedule an appointment, and most are open evenings and weekends. If your doctor's office is closed, an urgent care center is a good choice because:
- They usually don't require appointments
- They are open later than most doctors' offices
- They provide faster care at a price lower than most hospital emergency rooms.
Check your provider directory to see which urgent care centers are available in your plan’s network. Emergency roomWhen you have a life-threatening injury or condition, always go to the emergency room – preferably at a network hospital – or call 911. If you think you have a serious medical problem—like a stroke or heart attack—please play it safe. Get emergency care right away if you have any of these concerns:
- Chest pain
- Trouble breathing
- Bleeding or vomiting that won't stop
- Major burns, cuts, or breaks
- Loss of consciousness
- Signs or symptoms of a stroke
- Any threat to life or limb
These are just examples of situations that require Emergency Room treatment. More information is available at this link: Emergency Care Information. Your plan covers true emergencies at in-network and out-of-network providers, and no referrals or prior authorizations are needed. You can search "Hospital" under Humana's online “Find a Doctor” search tool to find a hospital emergency room in your Humana 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 a facility in your plan’s network and save money. HumanaFirst Nurse Advice LineIf 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. If you get your Humana insurance through your employer, ask your employer if this service is part of your plan. Outpatient care centers and surgery centersOutpatient care centers can take care of many 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. Check your provider directory to see which outpatient care and surgery centers are available in your plan’s network. Care in the hospitalYou may have to stay in the hospital for some medical problems. Hospital care is usually very expensive, and you may have other options in some cases. Talk with your doctor before you make any decisions about hospital care. Ask your doctor if you can use an outpatient center or urgent care center instead of going into a hospital. If you do need to stay in a hospital, be sure to choose a hospital in your plan's network. Care away from homeWhen you're traveling, you can save money by using providers in your Humana network. When you're away from home, call the number on your Humana ID card to find an in-network provider. Or, before you go, log in to your personal account on Humana.com and use the "Find a Doctor” search tool to look for doctors and hospitals in the area you're going to visit. Your health plan may not let you use providers who are not in your plan's service area. See your coverage details, or call Member Service for specific details about your plan.If you need emergency care while traveling, go to the nearest emergency room. Your plan covers true emergencies at in-network and out-of-network providers.If you are traveling and become ill, call Member Service to see if your plan offers an in-network urgent care center or retail clinic in that area.
Finding a provider in your network
What is a network?A network is a group of providers in a certain service area that have a contract to 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 submits your claims to Humana 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. Some plans do not provide any coverage for care received from out-of–network providers, except in life-threatening emergencies. Check your coverage details or call Member Service for specific details about your plan. Choose a Primary Care Physician (PCP) from Humana's in-network doctorsBesides a primary care 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 (PCP) 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 could save you time and money, and may also help you prevent health problems.Remember, with some plans, you must choose a primary care physician to oversee your medical care and provide referrals when you need to see a specialist. Check your policy to see if your specific plan requires this. Find a doctorHumana has different networks of providers for different health plans, so it is important to be sure you select providers from the specific network for your plan. Search for providers using the “Find a doctor or pharmacy” tool on the main page of Humana.com. You can enter your Member ID number from your Humana ID card at the beginning of your search, and you will see only the providers that are in your health plan’s network.Or, you can log in to your personal account on Humana.com and use the “Find a doctor” tool there. When you are logged-in, the search tool automatically selects the correct provider network for your plan. Read more about saving money by using in-network providers. You can find a provider by:
- Location – You can choose someone near your home or in a specific county or zip code.
- Provider type – Get the provider or specialty you need, including doctors, hospitals, clinics, pharmacies, and more.
- Name – You can look up a specific provider by name.
- Language – You can look for a doctor who speaks the language you or a family member needs.
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.
Please call the Member Service number on your Humana ID card before you look for a mental health provider on this Website. Some health plans use a different network of providers for mental health. Our Member Service Specialists will help you find the right providers for your plan. If it is a life-threatening situation, call 911 or go to the nearest emergency room.
Getting the most from your drug benefit
If your plan includes drug benefits, log into your personal account on Humana.com and view the Pharmacy page under “Coverage, Claims & Spending” for helpful information on your specific benefits. The page has a drug pricing tool where you can find out if your plan covers a specific drug, get cost estimates, and get information on generic drugs and lower-cost alternative drugs. You can also look up a Humana network pharmacy, find information on getting your prescription drugs by mail-order, and learn about drug interactions and side-effects.
Special Health Programs
Humana has special services to help you if you have complicated medical conditions or certain chronic conditions. Our case management service offers support to members with complicated medical conditions, or those who have been hospitalized. A Humana nurse helps you navigate the healthcare system and assists in coordinating care. Other services help people manage health conditions like diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), and other illnesses. These services are voluntary. If you are contacted about one of these special services, we encourage you to participate as most members find these programs to be very helpful. You may choose to discontinue at any time by just letting your care manager know. If you would like more information about these special health services 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 network providers. The rights and responsibilities statement reminds members and healthcare providers of their roles in maintaining a productive relationship.
View Member Rights
Quality Improvement (QI) Program
Humana wants to provide you with quality care so we have developed a program to make sure we are always improving. This is called the Quality Improvement 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 printed copy of the quality improvement (QI) program description and progress report by calling 1-800-4-HUMANA (1-800-448-6262), or provide input into the QI Program by writing to:
Humana Quality Operations and Compliance Department
321 West Main, WFP 20
Louisville, KY 40202
New Medical Technology
Humana decides about coverage of new medical procedures and devices on an ongoing basis. Humana's technology assessment department evaluates new medical devices and procedures approved by the U.S. Food and Drug Administration (FDA) to determine if they should be covered by Humana’s health plans. The Humana review assesses whether 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.
At Humana, a process called utilization management (UM) is used to determine whether a service or treatment is medically necessary 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.
If you ever disagree with a coverage decision, you can ask to have your case reviewed through an independent review process. Just call Member 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 Service at the toll-free number on your Humana ID card. We will try to resolve any problem you might have over the phone. Member Service can also provide you with information on submitting a formal written complaint.
Appealing a decision
Contact Member Service to discuss any questions or concerns you may have about your health plan coverage. Most questions 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 Service can explain your appeal rights and how to submit an appeal. You also can have this information sent to you in writing.