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 26* 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 and received by the last day of the month for your coverage to be effective on the 1st of the following month. If it is submitted on or after the 1st of the month, your coverage will be effective on the 1st of the following month.
- If you choose to pay by ACH (E-Check), your application must be submitted and received by the last day of the month for your coverage to be effective on the 1st of the following month. If it is submitted on or after the 1st of the month, your coverage will be effective on the 1st of the following month.
C. How does the HumanaOne Loyalty Plus PPO Plan Work?
Under our Loyalty Plus dental plan, you can choose to visit any dentist from the HumanaOne network, no primary care dentist required. There are more than 200,000 dentist locations nationwide to choose from. Simply present your HumanaOne Dental identification (ID) card when you see your dentist. It contains all the information your dentist needs to submit your claims. You can visit an in-network or out-of-network dentist, with the same coverage for services.
After HumanaOne Dental processes your dental claim, you will receive an explanation of benefits or claims receipt. It provides detailed information on covered dental services, amounts paid, plus any amount you may owe your dentist.
The HumanaOne Dental Loyalty Plus plan offers loyal members increasing benefits from plan years one to three. These increasing benefits include paying less out-of-pocket for services like fillings, root canals, crowns, and other services; an increase in plan year annual maximums; a one-time deductible for as long as you’re on the plan; and no copayments or waiting periods. Most preventive services are covered at 100 percent. Also, the plan pays the same percentage no matter which dentist you visit. Out-of-network dentists can bill you for charges above the amount covered by your HumanaOne Dental plan. To ensure you do not receive additional charges, visit a dentist in the HumanaOne Dental Loyalty Plus network. Limitations and exclusions may apply; please see your policy for coverage details.
D. Annual Deductible and Calendar Year Maximum
The HumanaOne Loyalty Plus dental plan has increasing over 3 years annual maximum from $1,000 to $1500 per person per year; One-time deductible for as long as you stay on the plan-$150 deductible for an individual, $300 for a two person plan and $450 for a family (no deductible for Preventive services).
E. 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.
F. 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.
G. Termination Policy
This is a 12-month contract.
This is an outline of the limitations and exclusions for the HumanaOne Dental Loyalty Plus plan listed above. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions:
- Any expenses incurred while you qualify for any worker’s compensation or occupational disease act or law, whether or not you applied for coverage.
- That are free or that you would not be required to pay for if you did not have this insurance, unless charges are received from and reimbursable to the U.S. government or any of its agencies as required by law;
- Furnished by, or payable under, any plan or law through any government or any political subdivision (this does not include Medicare or Medicaid); or
- Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected with sickness or bodily injury.
- Any loss caused or contributed by:
- War or any act of war, whether declared or not;
- Any act of international armed conflict; or
- Any conflict involving armed forces of any international authority.
- Any expense arising from the completion of forms.
- Your failure to keep an appointment with the dentist.
- Any service we consider cosmetic dentistry unless it is necessary as a result of an accidental injury sustained while you are covered under the policy. We consider the following cosmetic dentistry procedures:
- Facings on crowns or pontics (the portion of a fixed bridge between the abutments) posterior to the second bicuspid.
- Any service to correct congenital malformation;
- Any service performed primarily to improve appearance; or
- Characterizations and personalization of prosthetic devices.
- Charges for:
- Any type of implant and all related services, including crowns or the prosthetic device attached to it.
- Precision or semi-precision attachments.
- Overdentures and any endodontic treatment associated with overdentures.
- Other customized attachments.
- Any service related to:
- Altering vertical dimension of teeth;
- Restoration or maintenance of occlusion;
- Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth;
- Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction; or
- Bite registration or bite analysis.
- Infection control, including but not limited to sterilization techniques.
- Fees for treatment performed by someone other than a dentist except for scaling and teeth cleaning, and the topical application of fluoride that can be performed by a licensed dental hygienist. The treatment must be rendered under the supervision and guidance of the dentist in accordance with generally accepted dental standards.
- Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.
- Prescription drugs or pre-medications, whether dispensed or prescribed.
- Any service not specifically listed in your plan benefits.
- Any service shown as “Not Covered” in the Schedule.
- Any service that we determine:
- Is not a dental necessity;
- Does not offer a favorable prognosis;
- Does not have uniform professional endorsement; or
- Is deemed to be experimental or investigational in nature.
- Orthodontic services.
- Any expense incurred before your effective date or after the date your coverage under the policy terminates.
- Services provided by someone who ordinarily lives in your home or who is a family member.
- Charges exceeding the reimbursement limit for the service.
- Treatment resulting from any intentionally self-inflicted injury or bodily illness.
- Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans, occlusal adjustments, or tissue preparation associated with the impression or placement of a restoration when charged as a separate service. These services are considered an integral part of the entire dental service.
- Repair and replacement of orthodontic appliances.
- Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular joint disorder, craniomaxillary, craniomandibular disorder or other conditions of the joint linking the jaw bone and skull; or treatment of the facial muscles used in expression and chewing functions, for symptoms including, but not limited to, headaches.
- Elective removal of non-pathologic impacted teeth.
I. 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.