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 Preventive Plus PPO Plan Work?
Under our Preventative Plus dental plan, you can choose to visit any dentist from the HumanaOne network, no primary care dentist required. There are more than 130,000 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.
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.
There are no copayments for office visits. Most preventive services are covered at 100 percent with in-network providers. With in-network providers, many basic services are covered 50 percent and most major services may be offered at significant discounts. There is no waiting period for preventive services; six (6) month waiting period for basic services. Basic services include fillings, extractions, oral surgery, palliative treatment/pain relief, and re-cementation of crowns/bridges/inlays and onlays.
D. Annual Deductible and Calendar Year Maximum
The HumanaOne Preventive Plus dental plan has $1,000 annual maximum per person per year; $50 deductible for an individual, $100 for a two person plan and $150 for a family.
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 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.
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.