Dental Value Plan HI215-TX
Dental Value Plan HI215Plan Information
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 HI215 work?
Under our Dental Value Plan HI215, you must select a primary dentist from the HumanaOne 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 Dental Value Plan HI215. 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 HI215 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 ten (10) days of your effective Date (except New Hampshire, which is 30 days from effective date). If you cancel your membership within the above allotted cancellation period, you will be refunded your premium (not the enrollment fee). You will also be responsible for the full cost of any services received during this time period. The enrollment fee is non-refundable in all situations.
J. Termination Policy
This is a 12-month contract.
This is an outline of the limitations and exclusions for the plan listed above. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. Company does not provide coverage for:
- Services of any dentist other than a Participating General Dentist, except out-of-area emergency care as explained in the certificate;
- Procedures not specifically listed as a covered benefit in the certificate;
- You will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy other privileges of a Member in good standing whenever any Contributions or Copayments are delinquent;
- Dental treatment started prior to the Member’s effective date for eligibility of benefits;
- Services which in the opinion of the Participating General Dentist or Company are not necessary treatment to establish and/or maintain oral health;
- Services that are not appropriate or customarily performed for the given condition, do not have uniform professional endorsement, do not have a favorable prognosis, or are experimental or investigational;
- Services that are not consistent with the normal and/or usual services provided by the Participating General Dentist or which in the opinion of the Participating General Dentist would endanger health;
- Services or procedures which the Participating General Dentist is unable to perform because of the general health or physical limitations of the patient;
- Procedures, appliances or restorations to change vertical dimension, or to diagnose or treat abnormal conditions of the temporomandibular joint (TMJ); or replacement of lost, missing or stolen appliances;
- Services performed primarily for cosmetic purposes;
- Services provided by a Participating Pediatric Dentist to children over the age of seven;
- Removal of asymptomatic third molars unless pathology (disease) exists;
- Services for treatment of bodily injury or sickness that arose from or was sustained in the course of any occupation or employment for compensation, profit or gain;
- Crowns, inlays, onlays, or veneers for the purpose of: altering vertical dimension of teeth; restoring/maintaining occlusion; splinting teeth, or replacing tooth structure lost as a result of wear.
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 there under 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.