Dental Value Plan C550-GA
A. Enrollment and Eligibility
You may enroll yourself and your dependents, provided you reside or work in the service area. The Service Area is the geographical area in which HumanaOne has a panel of Contracted Dentists.
- Your unmarried children up to age 19 or age 23* if a full-time student and dependent upon you for support;
- Your children who are incapable of self-sustaining employment due to developmental disability or physical handicap and who depend on you for their support and maintenance. You must furnish HumanaOne with proof of dependent status, as provided by law.
(*limiting age may vary based upon state of residence)
B. Your Effective Date
Depending on your payment choice, coverage for you and your enrolled dependents will begin as follows:
- If you choose to pay by Credit Card, your application must be submitted by the 14th of the month for your coverage to be effective on the 1st of the following month. If it is submitted after the 14th of the month, your coverage will be effective on the 1st of the second following month.
- If you choose to pay by ACH (E-Check), your application must be submitted by the 12th of the month for your coverage to be effective on the 1st of the following month. If it is submitted after the 12th of the month, your coverage will be effective on the 1st of the second following month.
C. How does the HumanaOne Dental Value Plan C550 plan work?
Under our C Series DHMO plans, you must select a primary dentist from the HumanaOne DHMO network. Your primary dentist will provide all of your routine dental care. When you visit your primary care dentist, simply present your HumanaOne identification card. You may be required to pay a co-payment for some services provided by your primary care dentist. If the dental services provided are not listed as covered procedures under the plans, the primary care dentist will bill you at a 25% discount off normal fees.
Should you require the services of a specialist, you can choose any in-network specialist under the HumanaOne DHMO plan. All in-network specialists have agreed to provide HumanaOne members a 25% discount for all procedures.
The co-payments or discounted charges are billed at the time of service and will be the full portion of your cost for dental services, so there are no claim forms to file. You pay your dentist directly, if applicable.
D. Annual Deductible and Calendar Year Maximums
The HumanaOne Dental Value Plan C550 plan has no annual deductibles or maximum limitations on benefits.
E. Choice of Provider
When you enroll in the HumanaOne Plan, you and each enrolled family member must choose a Selected Participating Dental Office from the HumanaOne network. Each family member may select a different dental office.
F. Specialty Care/Specialist Referrals
If you need to see a specialist (like an Endodontist, Orthodontist, Oral Surgeon, or a Pediatric Dentist), you still have benefits. When you identify yourself as a HumanaOne member, the specialist will provide services at a 25% discount from the usual fee. You must use a HumanaOne network specialist to get this benefit.
G. Emergency Dental Services
If you have a dental emergency, contact your current dentist for an emergency appointment. If he or she is unable to see you, please contact Member services for specific emergency benefit information and procedures.
H. Coordination of Benefits
If you or your family members are covered by more than one dental care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific dentists. It may not be possible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers your family and you.
I. Cancellation Policy
You may cancel your Policy:
- By notifying HumanaOne in writing within thirty (30) days of the Effective Date. Provided no Dental Care Services have been rendered, all Contributions (excluding Enrollment Fees) will be refunded upon written request. If Dental Care Services have been received, then any Contribution refunds shall be first applied to the Usual Charges of the Participating General Dentist or Participating Specialist.
- If you permanently move from the HumanaOne service area. Cancellation shall become effective on the last day of the month in which written notification is received by Company.
- If you seek cancellation after the first thirty (30) days and during the first twelve (12) months of the Policy, you will not be entitled to any premium refund. Additionally, HumanaOne Participating General Dentists and Participating Specialists, at their discretion, shall have the right to collect from you their Usual Charges less any Copayments previously paid.
J. Termination Policy
This is a 12-month contract.
- No Service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate.
- Whenever any Contributions or Copayments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any other privileges of a Member in good standing.
- Company does not provide coverage for the following services:
- Cost of hospitalization and pharmaceuticals, drugs or medications.
- Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member’s oral health.
- Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member.
- Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member.
- Any dental treatment started prior to the Member’s effective date for eligibility of benefits.
- Services for injuries and conditions which are paid under Workers’ Compensation or Employers’ Liability Laws.
- Treatment for cysts, neoplasms and malignancies.
- General anesthesia
L. Grievance Procedures
Any Member who has a grievance against Company from any matter arising out of a Subscriber Certificate or for covered Dental Care Services rendered thereunder may submit an informal oral grievance to Company. Assistance with Company’s grievance procedures, including assistance with informal oral grievances, may be obtained by calling Company’s Member Services Department. Oral grievances shall be submitted to Company’s Grievance Coordinator. Informal oral grievances shall be responded to as soon as possible by the Grievance Coordinator. If the informal grievance involves a dentally-related matter or claim, Company’s Dental Director shall be involved in resolving said grievance. The Member has the right to file a formal written grievance with the Company.
Any Member who has a grievance against Company for any matter arising out of a Subscriber Certificate or for covered Dental Care Services rendered thereunder may submit a formal written statement of the grievance to Company. Such written statement shall be specifically identified as a grievance, shall be submitted to Company within one (1) year from occurrence of the events upon which the grievance is based, and shall contain a statement of the action requested, the Member’s name, address, telephone number, Member number, signature and the date. The statement should be sent to the Company’s Grievance Coordinator. More information on and assistance with Company’s grievance procedures may be obtained by calling Company’s Member Services Department.