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HMO
HumanaHMO provides you with more coverage than traditional medical insurance, including many preventive care benefits to maintain your good health. Most services are covered 100% or 100% after a small copayment—$20 for office visits with your primary care physician and $30 for office visits with a specialist. There are no deductible amounts to pay or claim forms to file.

The HMO contracts with group practice physicians, hospitals and other health care professionals in your community, including many Advocate providers. To receive benefits under the HMO, you must choose a primary care physician (PCP) from the plan's provider directory. Your PCP will provide or arrange for your health care services. Whenever you need medical services, you must receive care arranged by your PCP.

With the exception of emergency room services, copayments are waived at Advocate hospitals.

Not sure if participating in an HMO is right for you? Here are a few questions you may want to ask yourself:

Do you prefer to pay a set amount when you see your doctor? In the HMO you pay a set copayment for most services, and in the PPOs you pay a coinsurance fee, which is a percentage of the total cost of the service.
Do you mind paying a deductible before benefits are paid? In the HMO you do not need to meet a deductible before benefits are paid, but you must meet an annual deductible in the PPOs before benefits are paid (for services other than preventive care).
Do you need flexibility in terms of which physicians you can see? In the HMO, you must select a primary care physician (PCP), who then coordinates your care with specialist. Benefits are only payable if you see your primary care physician and other HMO physicians to which your PCP provides a referral. In the PPOs, you can see any doctor you choose (although benefits are payable at different levels depending on whether the doctor you see participates in the PPO’s network or not). Note: The copayment for a doctor's office visit is $20 when you see your primary care physician and $30 when you see a specialist.

This is a brief plan description, not the plan document. It doesn't include all of the benefits, limitations and exclusions of the plan. More complete terms of the plan are contained in the certificate of coverage, certificate of insurance, or Plan Summary.

For answers to questions about general plan features or claims, contact the plan administrator, Humana — by phone at 1-866-636-2371 (8 a.m. to 6 p.m., Monday-Friday), or online at www.humana.com. See the Benefits Directory for the phone number to call if you are hearing impaired or for Behavioral Health precertification, and for an address for written correspondence.

Services How Humana HMO Works
Hospital and surgery centers
Inpatient care $200 copayment each admission
 
Outpatient surgery $100 copayment each visit
 
Outpatient non-surgical care $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Emergency room $75 copayment each visit
--copayment is waived if patient is admitted
 
Physician
Routine physical exams $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Well-child care $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Office visits for treatment of illness or injury $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Pediatric care $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Immunizations $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Diagnostic lab tests and
x-rays		 $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
In-office allergy treatments and materials $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Casts, splints, crutches, braces and prosthetic devices $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Hearing and vision screening exams including eye refractions $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Hearing and vision exams due to illness or injury $20 copayment each visit ($30 copayment each visit if seen by a specialist)
 
Outpatient surgery $100 copayment per procedure
 
Infertility $30 copayment each visit
 
Inpatient care No charge
 
Other medical services
Chiropractic care $30 copayment each visit, spinal manipulations as determined to be medically necessary by PCP
 
Home health care No charge
 
Skilled nursing facility No charge
 
Durable medical equipment No charge
 
Physical, occupational
and speech therapy		 No charge
 
Behavioral health care
Care must be PRECERTIFIED Care must be PRECERTIFIED. Please call 1-800-331-9040.
 
Mental and nervous disorders
Inpatient No charge, up to 30 days each calendar year
 
Outpatient $30 copayment each visit, up to 20 visits each calendar year
 
Alcoholism & chemical dependency
Inpatient No charge, up to 30 days each calendar year
 
Outpatient $30 copayment each visit up to 20 visits each calendar year
 
Prescription drugs Provided through the Advocate Medical Plan Pharmacy Benefit (see Prescription Drug Benefits)

Important! When you have the opportunity to use an Advocate facility, Advocate will waive the amount you would otherwise pay—the inpatient or outpatient surgical copayment under HMO coverage. This waiver will NOT apply to emergency room copayments, nor will it apply to the charges of non-Advocate facilities—even if Advocate does not provide the service you need or if an Advocate facility is busy (“on by-pass”) at the time the service is provided.