Golden Rule Insurance Company is the underwriter of these plans.
This product is administered by Dental Benefit Providers, Inc.
Policy Forms GRI-DEN3-JR, -50(AK), -01 (AL), -02 (AZ), -03 (AR), -04 (CA), -05 (CO), -06 (CT), (DE),
-09 (FL), -10 (GA), -51 (HI), -12 (IL), -13 (IN), -14 (IA), -15 (KS), -16 (KY), -17 (LA), -18 (ME), -19 (MD),
-21 (MI), -22 (MN), -23 (MS), -24 (MO), -26 (NE), -27 (NV), -30 (NM), -32 (NC), -33 (ND), -35 (OK), -36 (OR),
-37 (PA), -38 (RI), -39 (SC), -40 (SD), -41 (TN), -42 (TX), -43 (UT), -44 (VT), -47 (WV), -48 (WI), and -49 (WY);
GRI-DEN3-JR-PB, -11 (ID), -34 (OH), -46 (WA); GRI-DEN3-JR-PBM, -11 (ID), -34 (OH), -46 (WA)
1
Primary Preferred and Primary Preferred Plus are the only plans available in CO and MN.
Primary Plus and Primary Preferred Plus are the only plans available in AK, ND, NV, SD, VT & WY.
2
The optional vision benefit is not available in MN, RI or WA.
Table of Contents
Why Dental Primary? 2
Dental Primary & Primary Plus 3
Dental Primary Preferred &
Primary Preferred Plus 4
Hearing Discounts 5
Optional Vision Benefits 6
Exclusions & Limitations 7
Notice of Privacy Practices 11
Wisconsin Outline of Coverage 15
California Notices 19
Dental Primary Plans
4 Plans
1
for Individuals & Families
with Optional Vision Benefits
2
The ratio of incurred claims to earned premiums (loss-ratio) for total accident and health for Golden Rule Insurance Company in all states in 2018 was 65.5%.
This is an outline only and is not intended to serve as a legal interpretation of benefits. Reasonable effort has been made to have this outline represent the intent of contract language.
However, the contract language stands alone and the complete terms of the coverage will be determined by the policy. State-specific differences may apply.
Jul 26 2019 10:17:41 am
What is your smile, your vision,
and your ability to hear worth?
Life can be more enjoyable when you feel comfortable
with your smile and can see and hear the world around you.
VISION CAN ADD VALUE
Vision health is vital to your lifestyle
and performance at home, work or
school. Dental Primary plans include
the option to add vision benefits to
help cover eye exams, glasses and
contacts. Additional premium required.
Available in most states. See pages 6
and 10 for details.
HEARING AID DISCOUNTS
*
Hearing health is essential for social conversations, alertness and overall
safety. EPIC Hearing Healthcare provides access to discounts on hearing
exams and aids. See page 5 for details.
* Hearing discounts are provided by EPIC Hearing Healthcare and are not insurance.
DENTAL PLANS FOR
THE FAMILY
Dental health is key to overall
health as well as the way you
look and feel. All Dental Primary
plans cover preventive routine
exams at 100% starting day one.
See pages 3 and 4 for details.
(Back to cover)
2 of 14
Jul 26 2019 10:17:41 am
Comparing Non-Network
vs. Network
4
Non-Network
Network
Both Plans
Primary
1,2
Primary Plus
3,2
Simple Filling
Retail charge:
$181.14
You pay:
$152.64 $90.57
$28.50
1
Pays non-network provider benefits based on the network negotiated rate.
2
Non-network dentists can bill a patient for any remaining amount up to the
billed charge.
3
Pays non-network provider benefits based on the reasonable
and customary charge.
4
Service pricing in ZIP Code 752-- using policy year
one and assuming the plan deductible has been met. Discounts vary by
policy year, type of provider, geographic area, and type of service.
PREVENTIVE CARE HAS
NO WAITING PERIOD
Primary
1,2
Designed to offer immediate coverage and
network discounts for preventive care and
basic services. Plan availability varies by state.
Lower Premium
4 Dental Gen Plans to choose from:
Find a dentist by clicking: my
uhc.com > Under Links and Tools, select “Find a Dentist” > Select your state and the “National Options PPO 30” network
OPTION TO ADD
VISION BENEFIT
ACCESS TO DISCOUNTS
ON HEARING AIDS
3 of 14
Preventive Care Services
(includes routine cleaning & exams)
Policy pays 100% day one
After Deductible:
Basic Services
(includes simple fillings & extractions)
Policy pays 50% day one
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals,
oral surgery, and bridges)
Not covered
Coverage Amount
(per calendar year)
$1,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles)
$50 per person
(basic services)
Most Valuable Feature
Lowest premium
of Dental Primary plans
Primary Plus
3,2
This plan pays more for non-network dentists on
basic services than the other plans. There is also
no waiting period for preventive care or basic services.
Plan availability varies by state.
Use Any Dentist
Preventive Care Services
(includes routine cleaning & exams)
Policy pays 100% day one
After Deductible:
Basic Services
(includes simple fillings & extractions)
Policy pays 50% day one
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals,
oral surgery, and bridges)
Not covered
Coverage Amount
(per calendar year)
$1,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles)
$50 per person
(basic services)
Most Valuable Feature
Network Flexibility
of higher non-network benefits
NO WAITING PERIODS
PREVENTIVE CARE
Jul 26 2019 10:17:41 am
Comparing Non-Network vs. Network
5
Non-Network
Network
Both Plans
Preferred
1,2
Preferred Plus
3,2
Simple Filling
Retail
charges:
$181.14
You pay:
$161.19 $117.74 $37.05
Molar Root Canal $1,255.36 $1,170.01 $1,067.06
$483.65
1
Pays non-network provider benefits based on the network negotiated rate.
2
Non-network dentists can bill a patient for any remaining amount up to the
billed charge.
3
Pays non-network provider benefits based on the reasonable
and customary charge.
4
50% in CT & IL.
5
Service pricing in ZIP Code 752--
using policy year one and assuming the plan deductible has been met. Discounts
vary by policy year, type of provider, geographic area, and type of service.
PREVENTIVE CARE HAS
NO WAITING PERIOD
Primary Preferred
1,2
Major services are covered, after a 6-month
waiting period, using network dentists. Plan
availability varies by state.
Primary Preferred Plus
3,2
Enjoy the flexibility of using network or non-network
dentists plus this plan covers major services after a
6-month waiting period.
4 Dental Gen Plans to choose from:
Find a dentist by clicking: my
uhc.com > Under Links and Tools, select “Find a Dentist” > Select your state and the “National Options PPO 30” network
OPTION TO ADD
VISION BENEFIT
ACCESS TO DISCOUNTS
ON HEARING AIDS
4 of 14
Use Any Dentist + Major ServicesIncludes Major Services
Preventive Care Services
(includes routine cleaning & exams)
Policy pays 100% day one
After Deductible:
Basic Services
(includes simple fillings & extractions)
Policy pays 35% day one
4
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals,
oral surgery, and bridges)
Policy pays 15% after
4
6-month waiting period
50% after policy year one
60% after policy year two
Coverage Amount
(per calendar year)
$1,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles)
$50 per person
(combined basic and major services)
Most Valuable Feature Major Services Coverage
Preventive Care Services
(includes routine cleaning & exams)
Policy pays 100% day one
After Deductible:
Basic Services
(includes simple fillings & extractions)
Policy pays 35% day one
4
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals,
oral surgery, and bridges)
Policy pays 15% after
4
6-month waiting period
50% after policy year one
60% after policy year two
Coverage Amount
(per calendar year)
$1,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles per service type)
$50 per person
(combined basic and major services)
Most Valuable Feature
Network Flexibility with
Major Services Coverage
NO WAITING PERIODS
PREVENTIVE CARE
Jul 26 2019 10:17:41 am
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65% of people
with hearing loss are
younger than age 65.
betterhearing.org
The Better Hearing Institute, 2018
Hearing Discount Example
Jen notices she often has to ask her family members to repeat themselves
to her, so she decides to get a hearing exam. Jen works with EPIC Hearing
Healthcare to schedule the hearing exam. After being diagnosed with some
hearing loss, EPIC calls Jen to discuss the different hearing aid options
available. She is able to find hearing aids for less than retail with EPIC’s help.
The cost of treatment can often be a prime
concern for someone who has hearing loss.
Did you know that studies have found that income
can be significantly decreased by not wearing
hearing aids? Hearing loss can pose a significant
barrier to everything from productivity and overall
career success to household earnings.
1
“Because
hearing loss often occurs gradually, it can be
difficult to recognize when you have it.”
2
Learn more about discounts on hearing exams and
hearings aids through EPIC Hearing Healthcare.
The people and events depicted here are fictional and do not represent actual cases.
EPIC HEARING HEALTHCARE
KEY FEATURES
Audiologist Appointment Scheduling
Access to Hearing Exams & Aids
45-day Trial Period for Hearing Aids
1-Year Supply of Batteries
Limited discounts available. Administered by EPIC Hearing Healthcare.
By calling toll free at 1-866-445-2079, EPIC can guide you through the
process, handling the audiologist referral so you don’t have to see your
primary care physician first
.
1
5 Ways Better Hearing Can Help Your Career, audiologyinc.net, October 2017
2
Regular Screenings are Important hearingofamerica.com, May 2017
Learn more about Epic hearing discounts: epichearing.com/GRICdental
ACCESS TO DISCOUNTS
ON HEARING AIDS
Jul 26 2019 10:17:41 am
Eye exams at every
age and life stage can help
keep your vision strong.
cdc.org Centers for Disease Control and Prevention,
July 2018
6 of 14
1
Vision benefit not available in MN, RI, or WA.
2
You may go outside the network, but are eligible for better discounts using network providers.
3
See eyeglass frames and lens coverage details on page 10.
Jane has vision coverage with her family’s dental plan. She is able to get
a new pair of glasses every 12 months for her daughter who needs them
more often as she grows. She can even get contacts in addition to glasses
every year when her daughter wants to change up her look.
OPTION TO ADD
VISION BENEFIT
1
The people and events depicted here are fictional and do not represent actual cases.
Popular retailers include:
Find additional retailers here.
20/20 Vision Center
America’s Best Costco Optical Eyeglass World
National Vision Sam’s Club Visionworks Walmart
Optional Vision Benefit Example
Our network includes private practices along with leading retail locations.
Administered by Spectera, Inc. Policy Form SA-S-1884-GRI
Additional premium required for adding the vision benefit. Not available in
all areas. Details and limits to coverage are listed in the policy.
Using your benefits is easy! Once your plan is
effective, review your benefit information. Find a
network doctor whos right for you to get the
most out of your eye care experience.
2
Mention
that you have UnitedHealthcare vision powered by
Spectera Eyecare Networks. Coverage starts day
one, no ID card needed, no claim forms to fill out.
COVERED EXPENSES
WHAT YOU PAY
Eye Exam
Once every
12 months
Network
$10 copay
Non-network
Any charge over $50 allowance
Eyeglass
Frames
3
Once every
12 months
Network
Any charge over $150 allowance
Non-network
Any charge over $75 allowance
Eyeglass
Lenses
One pair
every 12
months (of
any type)
3
Network
$10 copay
Non-network
Any charge over:
$40 allowance (Single Vision);
$60 allowance (Bifocal);
$80 allowance (Trifocal/Lenticular)
and Contacts:
Contacts
Once every
12 months
Network
Select Contact Lenses List:
$0 Copay
Non-Selection Contacts:
Any charge over $150 allowance
Non-network
Any charge over $105 allowance
Jul 26 2019 10:17:41 am
All Plans: Preventive Services
Routine exams and cleanings – limited to 2 per calendar
year
X-rays (bitewing) – limited to 1 series per calendar year
X-rays (full mount panoramic) – limited to 1 per 36 months
Eligible childrens services (under the age of 16; in IL,
under the age of 19):
- Fluoride treatments – limited to 2 times per calendar
year
- Space maintainers – limited to once per 60 months
plus adjustments within 6 months of installation.
- Sealants – limited to once per first and second
permanent molar every 36 months
All Plans: Basic Services
Fillings – amalgam and composite (composite is limited
to anterior tooth)
Simple nonsurgical extractions
General anesthesia – in conjunction with oral surgery or
the removal of 7 or more teeth
Local anesthesia
Preferred Plans Only: Major Services
(as limited in the policy)
Root canals – limit 1 time per tooth, per lifetime
Crowns – limit 1 per tooth, per 60 months
Surgical extraction of erupted tooth or roots – limited to
1 time per tooth per lifetime
Full dentures – limited to 1 per 60 months
Bridges – limited to 1 time per 60 months
Calendar Year vs. Policy Year
A calendar year runs from January to December and
starts over on January 1 of the following year. Each plan’s
annual maximum coverage amount and deductible apply
during the calendar year.
A policy year is the anniversary of the plans effective start
date. The increasing coinsurance applies to the plan’s
policy year.
Change or Misstatement of Residence (Address)
You must notify us within 60 days of changing your
residence. Your premium based on your new residence
will begin on the first due date after the change. If you
misstate your residence on the application or fail to notify
us of a change of residence, we will apply the correct
premium on the first due date you resided at that
residence. If the change results in: lower premium, we will
refund any excess; higher premium, you will owe us
(misstatement not applicable in AL or VT).
Eligibility
At the time of application, primary insured must be 18-64
years of age. Spouse (as defined by state) may be of any
age. Eligible children 0-25 years of age (drop off on 26th
birthday) or as required by state. In HI, an eligible
dependent includes a reciprocal beneficiary.
Misstatement of Age
If the covered persons age has been misstated on the
covered persons application for coverage under the
policy, any future premiums may be adjusted and past
premiums may be refunded or owed to us, or benefits
may be adjusted, based on the correct age. If a covered
persons age has been misstated and we would not have
issued coverage for that covered person, we will refund
the premium paid minus any benefit amounts paid by us,
and coverage would be void from the effective date.
Other Details
(all dental plans)
This is only a general
outline of the basic policy
provisions and exclusions.
State-specific differences
may apply. It is not an
insurance contract, nor
part of the insurance
policy. You will find
complete details in the
policy.
This brochure may be used in
the following states:
State-specific differences may apply. All services are subject to
annual maximums and may be subject to deductible and coinsurance.
Basic Policy Details
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
West Virginia
Wisconsin
Wyoming
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Jul 26 2019 10:17:41 am
Non-Network vs. Network
You may pay more using non-network providers.
Non-network providers may bill you for any amount up to
the billed charge after the plan has paid its portion.
Network providers have agreed to discounted pricing for
covered expenses with no additional billing to you other
than the copayment, coinsurance, and deductible
amounts.
Premium
You will be given at least a 31-day notice (or longer if
required by your state) of any change in your premium.
We will make no change in your premium solely because
of claims made by a covered person under the policy.
The covered persons type and level of benefits and place
of residence on the premium due date are some of the
factors that may be used in determining your premium rates.
Renewability and Termination
The policy is renewable until the earliest of the following:
The primary insured’s death. If the policy includes
dependents, it may be continued after the primary
insured’s death:
- By the spouse, if the spouse is a covered person
- Otherwise, by the youngest child who
is a covered person;
• Nonpayment of premiums when due;
The date we receive a request from you to terminate the
policy;
The date we decline to renew all policies issued on this
form with the same type and level of benefits in your state
of residence; or
The date there is fraud or a misrepresentation made by
or with the knowledge of a covered person.
General Exclusions and Limitations
No benefits will be paid for any services not identified or
included as covered expenses under the policy. You will be
fully responsible for payment for any services which are not
covered expenses.
No benefits are payable for any service or treatment
caused by, resulting from, for, which are, or relating to
any of the following:
Incurred prior to the effective date, during the waiting
period, or after the termination date of the policy.
Exceeds the non-network provider reimbursement, the
frequency limitations, or maximum benefits.
Not rendered within the scope of the dentist’s license.
Payable under a medical policy issued by us, except in
states that require this to be covered.
Hospital or other facility charges and related anesthesia
charges.
Conscious sedation, analgesia, anxiolysis, and inhalation
of nitrous oxide.
Surgical extraction of wisdom teeth.
Reconstructive surgery.
Cosmetic dentistry.
Oral hygiene instructions; plaque control; charges for
completing dental claim forms; photographs; any dental
supplies; prescription and non-prescription drugs, that are
not dispensed and utilized in the dental office during your
visit; sterilization fees; treatment of halitosis and any
related procedures; lab procedures.
Removal of sound functional restorations; temporary
crowns and temporary prosthetics; provisional crowns
and provisional prosthesis.
Acupuncture, acupressure, and other forms of alternative
treatment.
Telephone consultations or for failure to keep a scheduled
appointment.
Other Details
(all dental plans)
This is only a general
outline of the basic policy
provisions and exclusions.
State-specific differences
may apply. It is not an
insurance contract, nor
part of the insurance
policy. You will find
complete details in the
policy.
This brochure may be used in
the following states:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
West Virginia
Wisconsin
Wyoming
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Jul 26 2019 10:17:41 am
General Exclusions and Limitations, continued
No benefits are payable for any service or treatment
caused by, resulting from, for, which are, or relating to
any of the following:
Bone grafts, guided tissue regeneration, biologic materials
to aid in soft and osseous tissue regeneration when
performed in edentulous (toothless areas, ridge
augmentation or preservations).
Intoxication, as defined by applicable state law in the state
where the loss occurred, or under the influence of illegal
narcotics or controlled substance, unless administered or
prescribed by a doctor.
Experimental or investigational treatment or complications
therefrom.
Which arise out of, or in the course of your employment
for wage or profit (CA, FL, NC – applies if paid by worker’s
compensation).
Any act of war, participation in a riot, intentionally self-
inflicted bodily harm, or commission or attempt to commit
a felony.
Provided free of charge without this insurance or by a
government plan or program.
Provided by a family member or by someone who
ordinarily resides with a covered person.
Received outside of the United States, except for a dental
emergency.
Related to temporomandibular joint, upper and lower jaw
bone surgery (does not apply in MN or NM), or
orthognathic surgery (does not apply in MN).
Teeth that can be restored by other means; periodontal
splinting, to correct abrasion, erosion, attrition, bruxism,
abfraction, or for desensitization; or teeth that are not
periodontally sound or have a questionable prognosis.
Maxillofacial prosthetics and related services.
Orthodontics or dental implants and any related
procedure.
To alter vertical dimension and/or restore or maintain
occlusion, bite analysis, or congenital malformation.
Setting of facial bony fractures and any treatment
associated with the dislocation of facial skeletal hard
tissue.
Treatment of benign neoplasms, cysts, or other pathology
involving benign lesions, except excisional removal;
treatment of malignant neoplasms or congenital
anomalies.
Mouthguards, precision or semi-precision attachments,
occlusal guards, bruxism appliances, duplicate dentures,
harmful habit appliances, replacement of lost or stolen
appliances, or sleep disorder appliances.
Provided as a result of a prohibited referral (MD only).
The following exclusion applies only to the Primary and
Primary Plus plans:
Major services, which include all procedures or services
related to endodontics, periodontics, major restorative
services (crowns, inlays, onlays and veneers), prosthetics
(bridges and dentures), and oral surgery.
The following Exclusions and Limitations apply to Primary
Preferred and Primary Preferred Plus plans for Major
Services:
Initial placement of full or partial dentures or bridges and
related services, to replace functional natural teeth that
are congenitally missing or lost before insurance under
the policy is in effect.
Replacement of full or partial removable dentures,
bridges, crowns, inlays, onlays, or veneers which can be
repaired or restored to natural function.
Replacement of complete dentures, fixed and removable
partial dentures or crowns if damage or breakage was
directly related to provider error.
Fixed or removable prosthodontic restoration procedures
for complete oral rehabilitation or reconstruction.
Placement of fixed partial dentures solely to achieve
periodontal stability.
Other Details
(all dental plans)
This is only a general
outline of the basic policy
provisions and exclusions.
State-specific differences
may apply. It is not an
insurance contract, nor
part of the insurance
policy. You will find
complete details in the
policy.
This brochure may be used in
the following states:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Washington
West Virginia
Wisconsin
Wyoming
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Jul 26 2019 10:17:41 am
Vision Details
(optional benefit)
How the Vision Program Works
Your out-of-pocket expenses – what you’ll owe for
vision services – will vary depending on the type of
provider you use:
For Network Vision Providers: After your copay, they
agree to accept the plan payment as full reimbursement
for covered expenses. Check our online list of providers.
They are categorized in three ways:
- Full service – are contracted to provide eye exams and
prescription eyewear at discounted rates.
- Exam Only – are contracted to provide exams ONLY at
discounted rates.
- Dispense Only – are contracted to dispense
prescription eyewear ONLY at discounted rates.
For Non-Network Vision Providers: You must pay
non-network providers in full at time of service.
Then you submit itemized copies of receipts and request
reimbursement from the UnitedHealthcare Vision Claims
department (administered by Spectera, Inc.). Your out-of-
pocket costs may be higher with a non-network provider.
Please Note: This vision benefit program is designed to
cover vision needs rather than cosmetic extras. If those are
selected, the plan will pay the costs of the allowed lenses
and you will be responsible for the additional cost of the
cosmetic extras.
Eyeglass Frames and Lenses
The eyeglass frames benefit includes their fitting and
subsequent adjustments to maintain comfort and
efficiency.
Eyeglass lenses may include single vision,
bifocal, and trifocal/lenticular lenses. Additional costs for
other types of lenses, lens materials and lens option extras
may apply.
Vision Benefit Exclusions and Limitations
No benefits are payable for the following vision expenses:
Orthoptics or vision therapy training and any associated
supplemental testing;
Plano lenses (a lens with no prescription on it);
Oversized lenses;
Replacement of eyeglass lenses and frames furnished
under this plan which are lost or broken except at the
normal intervals when services are otherwise available;
Medical or surgical treatment of the eyes;
Any eye examination or any corrective eyewear, required
by an employer as a condition of employment;
Corrective vision treatment of an experimental or
investigative nature;
Corrective surgical procedures such as, but not limited to,
Radial Keratotomy (RK) and Photorefractive Keratectomy
(PRK);
Eyewear except prescription eyewear;
Charges that exceed the allowed amount;
Services or treatments that are already excluded in the
General Exclusions and Limitations section of the
policy; and
Optional lens extras not listed in your policy.
Find a provider in your area.
Access your plan information.
See your claim status, and
more.
Find a vision provider by clicking here: my
UHCvision.com
This is only a general
outline of the basic policy
provisions and exclusions.
State-specific differences
may apply. It is not an
insurance contract, nor
part of the insurance
policy. You will find
complete details in the
policy.
This brochure may be used in
the following states:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Mississippi
Missouri
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
West Virginia
Wisconsin
Wyoming
10 of 14
Jul 26 2019 10:17:41 am
HEALTH PLAN NOTICES OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
MEDICAL INFORMATION PRIVACY NOTICE
(Effective January 1, 2019)
We (including our affiliates listed at the end of this notice) are required by law to protect
the privacy of your health information. We are also required to send you this notice, which
explains how we may use information about you and when we can give out or “disclose”
that information to others. You also have rights regarding your health information that are
described in this notice. We are required by law to abide by the terms of this notice.
The terms “information” or “health information” in this notice include any information we
maintain that reasonably can be used to identify you and that relates to your physical or
mental health condition, the provision of health care to you, or the payment for such
health care. We will comply with the requirements of applicable privacy laws related to
notifying you in the event of a breach of your health information.
We have the right to change our privacy practices and the terms of this notice. If we make
a material change to our privacy practices, we will provide to you in our next annual distribution,
either a revised notice or information about the material change or how to obtain a revised
notice. We will provide this information either by direct mail or electronically in accordance
with applicable law. In all cases, we will post the revised notice on our websites, such as
www.uhone.com, www.myuhone.com, www.uhone4me.com, www.myallsavers.com, or
www.myallsaversconnect.com.
We reserve the right to make any revised or changed notice
effective for information we already have and for information that we receive in the future.
We collect and maintain oral, written and electronic information to administer our
business and to provide products, services and information of importance to our
customers. We maintain physical, electronic and procedural security safeguards in the
handling and maintenance of our enrollees’ information, in accordance with applicable
state and Federal standards, to protect against risks such as loss, destruction or misuse.
How We Use or Disclose Information. We must
use and disclose your health information to
provide information:
To you or someone who has the legal right to act for you (your personal representative)
in order to administer your rights as described in this notice; and
To the Secretary of the Department of Health and Human Services, if necessary, to
make sure your privacy is protected.
We have the right to
use and disclose health information for your treatment, to pay for
your health care and operate our business. For example, we may use or disclose your
health information:
For Payment
of premiums due us, to determine your coverage and to process claims for
health care services you receive including for subrogation or coordination of other
benefits you may have. For example, we may tell a doctor whether you are eligible for
coverage and what percentage of the bill may be covered.
For Treatment.
We may use or disclose health information to aid in your treatment or the
coordination of your care. For example, we may disclose information to your physicians
or hospitals to help them provide medical care to you.
For Health Care Operations.
We may use or disclose health information as necessary to
operate and manage our business activities related to providing and managing your
health care coverage. For example, we might conduct or arrange for medical review, legal
services, and auditing functions, including fraud and abuse detection or compliance
programs. We may also de-identify health information in accordance with applicable
laws. After that information is de-identified, the information is no longer subject to this
notice and we may use the information for any lawful purpose.
To Provide Information on Health Related Programs or Products
such as alternative medical
treatments and programs or about health-related products and services.
To Plan Sponsors.
If your coverage is through an employer group health plan, we may
share summary health information and enrollment and disenrollment information with
the plan sponsor. In addition, we may share other health information with the plan
sponsor for plan administration if the plan sponsor agrees to special restrictions on its
use and disclosure of the information in accordance with Federal law.
For Underwriting Purposes.
We may use or disclose your health information for underwriting
purposes; however, we will not use or disclose your genetic information for such purposes.
For Reminders.
We may use or disclose health information to contact you for
appointment reminders with providers who provide medical care to you.
We may
use or disclose your health information for the following purposes under limited
circumstances:
As Required by Law.
We may disclose information when required to do so by law.
To Persons Involved With Your Care.
We may use or disclose your health information to a
person involved in your care, such as a family member, when you are incapacitated or in
an emergency, or when you agree or fail to object when given the opportunity. If you are
unavailable or unable to object we will use our best judgment to decide if the disclosure is in
your best interests. Special rules apply regarding when we may disclose health
information to family members and others involved in a deceased individuals care. We may
disclose health information to any persons involved, prior to the death, in the care or
payment for care of a deceased individual, unless we are aware that doing so would be
inconsistent with a preference previously expressed by the deceased.
For Public Health Activities
such as reporting disease outbreaks to a public health authority.
For Reporting Victims of Abuse, Neglect or Domestic Violence
to government authorities,
including a social service or protective service agency.
For Health Oversight Activities
such as licensure, governmental audits and fraud and
abuse investigations.
For Judicial or Administrative Proceedings
such as in response to a court order, search
warrant or subpoena.
For Law Enforcement Purposes
such as providing limited information to locate a missing
person or report a crime.
To Avoid a Serious Threat to Health or Safety
by, for example, disclosing information to public
health agencies or law enforcement authorities, or in the event of an emergency or
natural disaster.
33638-X-201902 Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule
Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.
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Jul 26 2019 10:17:41 am
For Specialized Government Functions
such as military and veteran activities, national
security and intelligence activities, and the protective services for the President and
others.
For Workers’ Compensation
including disclosures required by state workers’ compensation
laws that govern job-related injury or illness.
For Research Purposes
such as research related to the prevention of disease or disability,
if the research study meets Federal privacy law requirements.
To Provide Information Regarding Decedents.
We may disclose information to a coroner or
medical examiner to identify a deceased person, determine a cause of death, or as
authorized by law. We may also disclose information to funeral directors as necessary
to carry out their duties.
For Organ Procurement Purposes.
We may use or disclose information to entities that
handle procurement, banking or transplantation of organs, eyes or tissue to facilitate
donation and transplantation.
To Correctional Institutions or Law Enforcement Officials
if you are an inmate of a
correctional institution or under the custody of a law enforcement official, but only if
necessary (1) for the institution to provide you with health care; (2) to protect your health
and safety or the health and safety of others; or (3) for the safety and security of the
correctional institution.
To Business Associates
that perform functions on our behalf or provide us with services if
the information is necessary for such functions or services. Our business associates
are required, under contract with us and pursuant to Federal law, to protect the privacy
of your information and are not allowed to use or disclose any information other than
as specified in our contract and as permitted by Federal law.
Additional Restrictions on Use and Disclosure.
Certain Federal and state laws may require
special privacy protections that restrict the use and disclosure of certain health
information, including highly confidential information about you. Such laws may
protect the following types of information: Alcohol and Substance Abuse, Biometric
Information, Child or Adult Abuse or Neglect, including Sexual Assault, Communicable
Diseases, Genetic Information, HIV/AIDS, Mental Health, Minors’ Information,
Prescriptions, Reproductive Health, and Sexually Transmitted Diseases.
If a use or disclosure of health information described above in this notice is prohibited
or materially limited by other laws that apply to us, it is our intent to meet the
requirements of the more stringent law.
Except for uses and disclosures described and limited as set forth in this notice, we will
use and disclose your health information only with a written authorization from you. This
includes, except for limited circumstances allowed by Federal privacy law, not using or
disclosing psychotherapy notes about you, selling your health information to others or
using or disclosing your health information for certain promotional communications that
are prohibited marketing communications under Federal law, without your written
authorization. Once you give us authorization to release your health information, we
cannot guarantee that the person to whom the information is provided will not disclose
the information. You may take back or “revoke” your written authorization, except if we
have already acted based on your authorization. To revoke an authorization, call the phone
number listed on your health plan ID card.
What Are Your Rights.
The following are your rights with respect to your health information.
You have the right to ask to restrict
uses or disclosures of your information for treatment,
payment, or health care operations. You also have the right to ask to restrict
disclosures to family members or to others who are involved in your health care or
payment for your health care. We may also have policies on dependent access that
may authorize certain restrictions.
Please note that while we will try to honor your request
and will permit requests consistent with our policies, we are not required to agree to any restriction.
You have the right to ask to receive confidential communications
of information in a different
manner or at a different place (for example, by sending information to a
PO Box instead of your home address). We will accommodate reasonable requests
where a disclosure of all or part of your health information otherwise could endanger
you. In certain circumstances, we will accept verbal requests to receive confidential
communications; however, we may also require you to confirm your request in writing.
In addition, any request to modify or cancel a previous confidential communication
request must be made in writing. Mail your request to the address listed below.
You have the right to see and obtain a copy
of health information that we maintain about you
such as claims and case or medical management records. If we maintain your health
information electronically, you will have the right to request that we send a copy of your
health information in an electronic format to you. You can also request that we provide a
copy of your information to a third party that you identify. In some cases you may receive
a summary of this health information. You must make a written request to inspect and
copy your health information or have it sent to a third party. Mail your request to the
address listed below. In certain limited circumstances, we may deny your request to
inspect and copy your health information. If we deny your request, you may have the right
to have the denial reviewed. We may charge a reasonable fee for any copies.
You have the right to ask to amend information
we maintain about you such as claims and
case or medical management records, if you believe the health information about you is
wrong or incomplete. Your request must be in writing and provide the reasons for the
requested amendment. Mail your request to the address listed below.
If we deny your request, you may have a statement of your disagreement added to your
health information.
You have the right to receive an accounting
of certain disclosures of your information
made by us during the six years prior to your request. This accounting will not include
disclosures of information: (i) for treatment, payment, and health care operations
purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions
or law enforcement officials; and (iv) other disclosures for which Federal law does not
require us to provide an accounting.
33638-X-201902
Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule
Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.
12 of 14
Jul 26 2019 10:17:41 am
You have the right to a paper copy of this notice.
You may ask for a copy of this notice at
any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice. In addition, you may obtain a copy of this notice at
our websites such as
www.uhone.com, www.myuhone.com, www.uhone4me.com,
www.myallsavers.com, or www.myallsaversconnect.com.
You have the right to be considered a protected person.
(New Mexico only)
A “protected person” is a victim of domestic abuse who also is either: (i) an applicant
for insurance with us; (ii) a person who is or may be covered by our insurance; or
(iii) someone who has a claim for benefits under our insurance.
Exercising Your Rights
Contacting your Health Plan.
If you have any questions about this notice or want to
exercise any of your rights, you may contact a UnitedHealthOne Customer Call Center
Representative. For Golden Rule members call us at 800-657-8205 (TTY 711). For All
Savers members, call us at 1-800-291-2634 (TTY 711).
Filing a Complaint.
If you believe your privacy rights have been violated, you may file a
complaint with us at the address listed below.
Submitting a Written Request.
Mail to us your written requests to exercise any of your
rights, including modifying or cancelling a confidential communication, requesting copies
of your records, or requesting amendments to your record at the following address:
Privacy Office, 7440 Woodland Drive, Indianapolis, IN 46278-1719
You may also notify the Secretary of the U.S. Department of Health and Human Services of your
complaint.
We will not take any action against you for filing a complaint.
Fair Credit Reporting Act Notice.
In some cases, we may ask a consumer-reporting
agency to compile a consumer report, including potentially an investigative consumer
report, about you. If we request an investigative consumer report, we will notify you
promptly with the name and address of the agency that will furnish the report. You may
request in writing to be interviewed as part of the investigation. The agency may retain a
copy of the report. The agency may disclose it to other persons as allowed by the
Federal Fair Credit Reporting Act.
We may disclose information solely about our transactions or experiences with you to our
affiliates.
MIB.
In conjunction with our membership in MIB, Inc., formerly known as Medical
Information Bureau (MIB), we or our reinsurers may make a report of your personal
information to MIB. MIB is a not-for-profit organization of life and health insurance
companies that operates an information exchange on behalf of its members.
If you submit an application or claim for benefits to another MIB member company for
life or health insurance coverage, the MIB, upon request, will supply such company
with information regarding you that it has in its file.
If you question the accuracy of information in the MIB’s file, you may seek a correction
in accordance with the procedures set forth in the Federal Fair Credit Reporting Act.
Contact MIB at: MIB, Inc., 50 Braintree Hill Park Ste. 400, Braintree, MA 02184-8734,
1-866-692-6901,
www.mib.com.
FINANCIAL INFORMATION PRIVACY NOTICE
(Effective January 1, 2019)
We (including our affiliates listed at the end of this notice) are committed to maintaining
the confidentiality of your personal financial information. For the purposes of this
notice, “personal financial information” means information, other than health
information, about an insured or an applicant for coverage that identifies the individual,
is not generally publicly available and is collected from the individual or is obtained in
connection with providing coverage to the individual.
Information We Collect.
Depending upon the product or service you have with us, we may
collect personal financial information about you from the following sources:
Information we receive from you on applications or other forms, such as name,
address, age, medical information and Social Security number;
Information about your transactions with us, our affiliates or others, such as premium
payment and claims history; and
Information from a consumer reporting agency.
Disclosure of Information.
We do not disclose personal financial information about our
insureds or former insureds to any third party, except as required or permitted by law.
For example, in the course of our general business practices, we may, as permitted by
law, disclose any of the personal financial information that we collect about you,
without your authorization, to the following types of institutions:
To our corporate affiliates, which include financial service providers, such as other
insurers, and non-financial companies, such as data processors;
To nonaffiliated companies for our everyday business purposes, such as to process
your transactions, maintain your account(s), or respond to court orders and legal
investigations; and
To nonaffiliated companies that perform services for us, including sending promotional
communications on our behalf.
We restrict access to personal
financial information about you to employees, affiliates and
service providers who are involved in administering your health care coverage or
providing services to you. We maintain physical, electronic and procedural safeguards
that comply with Federal standards to guard your personal financial information.
Confidentiality and Security. We maintain physical, electronic and procedural
safeguards, in accordance with applicable state and Federal standards, to protect
your personal financial information against risks such as loss, destruction or misuse.
These measures include computer safeguards, secured files and buildings, and
restrictions on who may access your personal financial information.
Questions About this Notice.
If you have any questions about this notice, you may contact a
UnitedHealthOne Customer Call Center Representative. For Golden Rule members call us
at 1-800-657-8205 (TTY 711). For All Savers members, call us at 1-800-291-2634 (TTY 711).
The Notice of Privacy Practices, effective January 1, 2019, is provided on behalf of All
Savers Insurance Company; All Savers Life Insurance Company of California; Golden
Rule Insurance Company; Oxford Health Insurance, Inc.; UnitedHealthcare Insurance
Company; and UnitedHealthcare Life Insurance Company. To obtain an authorization to
release your personal information to another party, please go to the appropriate
website listed in this Notice.
33638-X-201902
Products are either underwritten or administered by: All Savers Insurance Company, All Savers Life Insurance Company of California, Golden Rule
Insurance Company, Oxford Health Insurance, Inc., UnitedHealthcare Insurance Company, and/or UnitedHealthcare Life Insurance Company.
13 of 14
Jul 26 2019 10:17:41 am
Top Dental Insurance Questions
© 2019 United HealthCare Services, Inc.
45585-G-0819
Conditions Prior To Coverage (Applicable with or without the Conditional Receipt)
Subject to the limitations shown below, insurance will become effective if the following conditions are met:
1. The application is completed in full and is unconditionally accepted and approved by Golden Rule Insurance Company.
2. The first full premium, according to the mode of premium payment chosen, has been paid on or prior to the effective date, and any check is honored on first
presentation for payment.
3. The policy is: (a) issued by Golden Rule Insurance Company exactly as applied for within 45 days from date of application; (b) delivered to the proposed insured;
and (c) accepted by the proposed insured.
Failure to include all material medical information or correct information regarding the tobacco use of any applicant may cause the Company to deny a future
claim and to void your coverage as though it has never been in force. After you have completed the application and before you sign it, reread it carefully.
Be certain that all information has been properly recorded.
Keep this document. It has important information.
14 of 14
Jul 26 2019 10:17:41 am
GRI-DEN3-OC-JR-48 Page 1 04/30/18
45631-G-1018
THIS POLICY IS NOT A MEDICARE SUPPLEMENT POLICY.
If you are eligible for Medicare, review the Guide to Health
Insurance for people with Medicare available from the
Company.
Read Your Policy Carefully -- This outline sets forth a brief
description of the important aspects of your policy. This is not the
insurance contract. Only the actual policy will control. The policy
sets forth in detail your and our rights and obligations. For this
reason, it is important that you READ YOUR POLICY
CAREFULLY!
In this outline, “you” or “your” will refer to the person for whom
this outline has been prepared, and “we,” “our,” or “us” will refer
to Golden Rule Insurance Company.
Dental Coverage -- Plans of this type are designed to provide
the covered persons with coverage for dental care. The cost
must be due to a covered dental service. Coverage is provided
for preventive, basic, major services (If you plan includes major
services) and orthodontic services (if your plan includes
orthodontic services). Coverage is subject to any deductible
amounts, coinsurance amounts, or other limitations that may be
set forth in the policy.
Dental Benefits
DENTAL BENEFITS: Benefits are limited to the dental
services described below, but only when each service is a
covered expense:
PREVENTIVE SERVICES
A. Dental prophylaxis (cleanings), limited to 2-3 per calendar year
depending on the plan.
B. Oral evaluations, limited to 2-3 per calendar year depending
on the plan.
C. Problem focused oral evaluations.
D. Intraoral - Complete Series of radiograph images, limited to 1
per 36 months. Vertical bitewings not allowed in conjunction
with a complete series.
E. Panoramic radiographs image, limited to 1 per 36 months.
F. Oral/Facial photographic images, limited to 1 per 36 months.
G. Intraoral bitewing radiograph, single image, limited to 4 per
calendar year.
H. Intraoral bitewing radiographs, limited to 1 series per calendar
year.
I. Intraoral periapical and intraoral occlusal radiographs image.
J. Extraoral radiographs, limited to 2 per calendar year.
K. Vertical bitewings 7-8 radiograph images, limited to 1 per 36
months.
L. Diagnostic casts, limited to 1 per 24 months.
M. Pulp vitality tests, limited to 1 charge per visit regardless of
the number of teeth tested.
N. Adjunctive pre-diagnostic testing that aides in detection of
mucosal abnormalities including premalignant and malignant
lesions, not to include cytology or biopsy procedure, limited to
1 per calendar year.
O. Bacteriological and viral cultures.
P. Fluoride treatments, limited to covered persons under the age
of 16 years, limited to 2 times per calendar year.
Q. Sealant, limited to covered persons under the age of 16 and
once per first and second permanent molar every 36 months.
R. Preventive resin restorations in a moderate to high caries risk
patient, limited to 1 per permanent tooth every 36 months.
S. Space Maintainers, limited to covered persons under the age
of 16 years, once per 60 months. Benefit includes all
adjustments within 6 months of installation.
T. Re-cement Space Maintainers, limited to 1 per 6 months after
initial insertion.
BASIC SERVICES
A. Amalgam restorations, resin-based composite restorations,
and gold foil restorations, (multiple restorations on one surface
will be treated as a single filling).
B. Simple extractions.
C. Desensitizing medicament.
D. General anesthesia, in conjunction with oral surgery or the
removal of 7 or more teeth.
E. Local anesthesia.
F. Therapeutic drug injection, limited to 1 per visit.
G. Palliative treatment, only if no other services other than exam
and radiographs were done on the same tooth during the visit.
H. Consultations, when not performed with exams or
professional visits.
I. For all covered expenses, the following dental services will be
considered part of the entire dental service and not eligible for
benefits as a separate service: cement bases; study models/
diagnostic casts; acid etch; and bonding agents.
MAJOR SERVICES (if included)
The following are included if your plan includes benefits for
Major Services:
A. Apexification/recalcification/pulpal regeneration, limited to 1
time per tooth per lifetime.
B. Apicoectomy/periadicular surgery, limited to 1 time per tooth
per lifetime.
C. Retrograde filling, limited to 1 per tooth per lifetime.
D. Hemisection, limited to 1 time per tooth per lifetime.
E. Root canal therapy, limited to 1 time per tooth per lifetime.
Reimbursement not allowed for retreatment by original
performing dentist in first 12 months.
F. Retreatment of previous root canal therapy. Reimbursement
not allowed for retreatment by original performing dentist in
first 12 months.
G. Root resection/amputation, limited to 1 time per tooth per
lifetime.
H. Therapeutic pulpotomy, limited to 1 time per tooth per lifetime.
I. Pulpal therapy (resorable filling), limited to 1 time per tooth per
lifetime. Covered for anterior or posterior teeth only.
J. Pulp caps (direct/indirect excluding final restoration), not
covered if utilized solely as a liner or base underneath a
restoration.
K. Pulpal debridement - primary and permanent teeth, limited to
1 per tooth per lifetime. Not covered on the same day as other
endodontic services.
L. Pulpal regeneration (completion of regenerative treatment in
an immature permanent tooth with a necrotic pulp) does not
include final restoration, limited to 1 per tooth per lifetime.
M. Coping, limited to 1 per tooth per 60 months. Not covered if
done at the same time as a crown on same tooth.
N. Crowns - retainers/abutments, limited to 1 per tooth per 60
months. Not covered if done in conjunction with any other
inlay, onlay and crown codes except post and core buildup
codes.
Golden Rule Insurance Company Applies to policies issued in Wisconsin
Outline of Coverage for Policy Form GRI-DEN3-OC-JR-48
(Please retain this outline for your records.)
Jul 26 2019 10:17:41 am
GRI-DEN3-OC-JR-48 Page 2 04/30/18
45631-G-1018
O. Crowns - restorations, limited to 1 per tooth per 60 months.
Covered only when a filling cannot restore the tooth. Not
covered if done in conjunction with any other inlay, onlay and
crown codes except post and core buildup codes.
P. Temporary crowns - restorations, limited to 1 per tooth per 60
months. Covered only when a filling cannot restore the tooth.
Not covered if done in conjunction with any other inlay, onlay
and crown codes except post and core buildup codes.
Q. Stainless steel crowns, limited to 1 time per tooth per 60
months. Covered only when a filling cannot restore the tooth.
R. Protective restoration, covered as a separate benefit only if no
other service, other than X-rays and exam, were performed on
the same tooth during the visit.
S. Inlays/onlays - retainers/abutments, limited to 1 per tooth per
60 months. Not covered if done in conjunction with any other
inlay, onlay and crown codes except post and core buildup
codes.
T. Inlays/onlays - restorations, limited to 1 per tooth per 60
months. Covered only when a filling cannot restore the tooth.
Not covered if done in conjunction with any other inlay, onlay
and crown codes except post and core buildup codes.
U. Pontics, limited to 1 time per tooth per 60 months.
V. Retainer - cast metal for resin bonded fixed prosthesis, limited
to 1 time per tooth per 60 months.
W. Pin retention, limited to 2 pins per tooth, not covered in
addition to cast restoration.
X. Post and cores, covered only for teeth that have had a root
canal therapy.
Y. Re-cement inlays/onlays, crowns, bridges, and post and core,
limited to those performed more than 12 months after the
initial insertion.
Z. Alveoloplasty, not covered for single tooth extractions.
AA. Biopsy, limited to 1 biopsy per site per visit.
BB. Frenectomy/frenuloplasty.
CC. Surgical incision, limited to 1 per site per visit.
DD. Removal of a benign cyst/lesions, limited to 1 per site per
visit.
EE. Removal of torus, limited to 1 per site per visit.
FF. Surgical root removal, limited to 1 time per tooth per lifetime.
GG. Surgical extraction of erupted tooth or roots, limited to 1
time per tooth per lifetime.
HH. Surgical extraction of impacted teeth, limited to 1 time per
tooth per lifetime.
II. Surgical access, surgical exposure, or immobilization of
unerupted teeth, limited to 1 time per tooth per lifetime.
JJ. Primary closure of a sinus perforation, limited to 1 per tooth
per lifetime.
KK. Placement of device to facilitate eruption of impacted tooth,
limited to 1 time per tooth per lifetime.
LL. Vestibuloplasty, limited to 1 time per 60 months.
MM. Excision of hyperplastic tissue or pericoronal gingival,
limited to 1 per site per 36 months.
NN. Appliance removal (not by dentist who placed appliance)
includes removal of arch bar, limited to once per appliance
per lifetime.
OO. Oroantral fistula closure, limited to 1 per site per visit.
PP. Transseptal fiberotomy/supra crestal fiberotomy, by report,
limited to 1 time per tooth per lifetime.
QQ. Bone replacement graft for ridge preservation, per site,
limited to 1 site per lifetime. Not covered in conjunction with
other bone graft replacement procedures.
RR. Tooth reimplantation and/or transplantation services, limited
to 1 per site per lifetime.
SS. Periodontal maintenance, limited to 2 per calendar year.
T T. Clinical crown lengthening, limited to 1 per quadrant or site
per 36 months.
UU. Gingivectomy or gingivoplasty, limited to 1 per quadrant per
36 months.
VV. Anatomical crown exposure, limited to 1 per quadrant per 36
months.
WW. Gingival flap procedure, limited to 1 per quadrant per 36
months.
XX. Bone replacement graft, limited to 1 per quadrant per 36
months.
Y Y. Osseous surgery, limited to 1 per quadrant per 36 months.
ZZ. Biological materials to aid in soft and osseous tissue
regeneration, limited to 1 per 36 months.
AAA. Guided tissue regeneration, limited to 1 per quadrant per
36 months.
BBB. Surgical revision procedure, limited to 1 per quadrant per
36 months.
CCC. Soft tissue surgery, limited to 1 per quadrant per 36
months.
DDD. Full mouth debridement, limited to 1 per 36 months.
EEE. Provisional splinting, not to be used to restore vertical
dimension or as part of full mouth rehabilitation, should not
include use of laboratory based crowns and/or fixed partial
dentures (bridges). Exclusion of laboratory based crowns or
bridges for the purposes of provisional splinting.
FFF. Scaling or root planing, limited to 1 per 24 months.
GGG. Localized delivery of antimicrobial agents via a controlled
release vehicle into diseased crevicular tissue, per tooth,
by report, limited to 3 sites per quadrant, or 12 sites total,
for refractory pockets, or in conjunction with scaling or
root planing, by report.
HHH. Fixed partial dentures (bridges), limited to 1 time per tooth
per 60 months.
III. Full dentures, limited to 1 per 60 months. No additional
allowances for precision or semi-precision attachments.
JJJ. Partial dentures, limited to 1 per 60 months. No additional
allowances for precision or semi-precision attachments.
KKK. Tissue conditioning - maxillary or mandibular, limited to 1
time per 12 months.
LLL. Relining and rebasing dentures, limited to relining/rebasing
performed more than 6 months after the initial insertion.
Limited to 1 time per 12 months.
MMM. Repairs or adjustments to full dentures, partial dentures,
bridges or crowns, limited to repairs or adjustments
performed more than 12 months after the initial insertion.
Limited to 1 per 6 months.
ORTHODONTIC SERVICES (if included)
The following are included if your plan includes benefits for
Orthodontic Services:
We will provide benefits for orthodontic services, as shown in the
policy Data Pages, for a covered eligible child under the age of 19.
Benefits for orthodontic services will be paid in equal monthly
installments over the course of the entire orthodontic treatment
plan, starting on the date that the orthodontic bands or
appliances are first placed or on the date a one-step orthodontic
procedure is performed.
Benefits for orthodontic services end when the active
orthodontic treatment ends or the orthodontic maximum is
reached, whichever comes first.
Amount Payable
We will pay the applicable coinsurance percentage in excess of
the applicable deductible amount and any copayment for the
actual cost of services and supplies that qualify as covered
expenses and are received while the covered person’s coverage
is in force under the policy.
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45631-G-1018
A new deductible amount must be met each calendar year.
The maximum benefit per covered person, per calendar year is
shown in the policy Data Pages.
Benefits for certain types of services will not be payable until
after the waiting period has been satisfied.
What Is Not Covered
No benefits will be paid for any service or treatment for which
charges incurred are not identified and included as covered
expenses under this policy. You will be fully responsible for
payment for any services for which charges incurred are not
covered expenses under this policy.
This policy does not pay benefits for any service or treatment
caused by, resulting from, for, which are, or relating to any of the
following:
A. Not a covered expense or for which no charge is made.
B. Fees/surcharges imposed on the covered person by a
provider but that are actually the responsibility of the provider
to pay.
C. In excess of the frequency limitations or maximum benefits as
shown in the policy Data Pages.
D. Covered expenses incurred during the waiting period.
E. Covered expenses which exceed the non-network provider
reimbursement, as shown on the policy Data Pages.
F. Which no benefit is described in this policy or on the Data Page.
G. A dental service that is not rendered or that is not rendered
within the scope of the dentists license.
H. Major services, which includes all procedures or services
related to endodontics, periodontics, major restorative
services (crowns, inlays, onlays and veneers), dental implants,
prosthetics (bridges and dentures, fixed or removable), and
oral surgery, unless your plan includes benefits for Major
Services.
I. Billed for incision and drainage if the involved abscessed tooth
is removed on the same date of service.
J. Telephone consultations or for failure to keep a scheduled
appointment.
K. Any service incurred directly or indirectly as a result of the
covered person being intoxicated, as defined by applicable
state law in the state in which the loss occurred, or under the
influence of illegal narcotics or controlled substance unless
administered or prescribed by a doctor or voluntary taking of
any over the counter drug unless taken in accordance with
the manufacturer’s recommended dosage.
L. Experimental or investigational treatment or for complications
there from, including expenses that might otherwise be
covered if they were not incurred in conjunction with, as a
result of, or while receiving experimental or investigational
treatment.
M. Which arise out of, or in the course of, employment for wage
or profit, if the covered person is insured, or is required to be
insured, by workers’ compensation insurance pursuant to the
applicable state or federal law.
N. Intentionally self-inflicted bodily harm (whether the covered
person is sane or insane, any act of declared or undeclared
war, a covered person taking part in a riot, or a covered
person’s commission or attempt to commit a felony, whether
or not charged.
O. Provided by a government plan, program, hospital or other
facility, unless by law a covered person must pay and it is
otherwise a covered expense or which by law must be
provided by an educational institution.
P. Provided without cost to a covered person in the absence of
insurance covering the charge.
Q. Provided by an immediate family member or someone who
ordinarily resides with a covered person.
R. Provided prior to the effective date or after the termination
date of this policy.
S. Received outside of the United States, except for a dental
emergency.
T. Related to the temporomandibular joint (TMJ), either bilateral
or unilateral. Upper and lower jaw bone surgery (including that
related to the temporomandibular joint). No coverage is
provided for orthognathic surgery, jaw alignment, or treatment
for the temporomandibular joint.
U. Teeth that can be restored by other means; for purposes of
periodontal splinting; to correct abrasion, erosion, attrition,
bruxism, abfraction, or for desensitization; or teeth that are not
periodontally sound or have a questionable prognosis as
determined by us.
V. Performed solely for cosmetic/aesthetic reasons. (Cosmetic
procedures are those procedures that improve physical
appearance such as internal/ external bleaching, veneers.)
W. Maxillofacial prosthetics and related services.
X. Reconstructive surgery, regardless of whether or not the
surgery is incidental to a dental disease, injury, or congenital
anomaly when the primary purpose is to improve
physiological functioning of the involved part of the body.
Y. Fixed or removable prosthodontic restoration procedures for
complete oral rehabilitation or reconstruction.
Z. Changing vertical dimension; restoring occlusion; bite
analysis, congenital malformation.
AA. Orthognathic surgery.
BB. Setting of facial bony fractures and any treatment associated
with the dislocation of facial skeletal hard tissue.
CC. Treatment of benign neoplasms, cysts, or other pathology
involving benign lesions, except excisional removal.
DD. Treatment of malignant neoplasms or congenital anomalies
of hard or soft tissue, including excision.
EE. Replacement of full or partial removable dentures, bridges,
crowns, inlays, onlays or veneers which can be repaired or
restored to natural function.
FF. Mouthguards; precision or semi-precision attachments;
duplicate dentures; harmful habit appliances; occlusal guard;
replacement of lost or stolen appliances; treatment splints;
bruxism appliance; sleep disorder appliance.
GG. Oral hygiene instructions; plaque control; charges for
completing dental claim forms; photographs; any dental
supplies including but not limited to take-home fluoride;
sterilization fees; diagnostic casts; treatment of halitosis and
any related procedures; lab procedures.
HH. Drugs/medications, obtainable with or without a
prescription, unless they are dispensed and utilized in the
dental office during the covered person’s dental visit.
II. Dental implants and any related procedures, including but not
limited to crowns, bridges, and dentures, unless your plan
includes benefits for implants.
JJ. Hospital or other facility charges and related anesthesia charges.
KK. Removal of sound functional restorations; temporary crowns
and temporary prosthetics; provisional crowns and
provisional prosthesis.
LL. Altering vertical dimension and/or restoring or maintaining
occlusion. Such procedures include, but are not limited to,
equilibrium, periodontal splinting, full mouth rehabilitation,
and restoration for misalignment of teeth.
MM. Non-intravenous conscious sedation, analgesia, anxiolysis,
inhalation of nitrous oxide and conscious sedation.
NN. Charges for dental services that are not documented in the
dentist records, that are not directly associated with dental
disease, or that are not performed in a dental setting.
OO. Orthodontic services, unless your plan includes benefits for
orthodontic services.
Jul 26 2019 10:17:41 am
GRI-DEN3-OC-JR-48 Page 4 04/30/18
45631-G-1018
PP. Acupuncture; acupressure and other forms of alternative
treatment, whether or not used as anesthesia.
QQ. Bone grafts, guided tissue regeneration, biologic materials
to aid in soft and osseous tissue regeneration when
performed in edentulous (toothless areas, ridge
augmentation or preservations).
RR. Two or more dental services are submitted and the dental
services are considered part of the same dental service to
one another, we will pay the most comprehensive dental
service.
SS. Two or more dental services are submitted on the same day
and the dental services are considered mutually exclusive
(when one dental service contradicts the need for the other
dental service), we will pay for the dental service that
represents the final treatment.
T T. Surgical extractions of wisdom teeth.
UU. Services for which benefits are payable under a medical
policy issued by us.
VV. If you plan includes orthodontic services, orthodontic
services do not include the installation of space maintainer,
any treatment related to treatment of the temporomandibular
joint, surgical procedure to correct a malocclusion,
replacement of lost or broken retainers and/or habit
appliances, repair of damages to orthodontic appliances,
and any fixed or removable interceptive orthodontic
appliances previously submitted for payment under this
policy.
The following are applicable if your plan includes benefits for
Major Services:
A. Initial placement of full or partial dentures or bridges and
related services, to replace functional natural teeth that are
congenitally missing or lost before insurance under this policy
is in effect.
B. Placement of fixed partial dentures solely for the purpose of
achieving periodontal stability.
C. Replacement within 60 consecutive months of the last
placement for full and partial dentures and replacement within
60 consecutive months of the last placement for crowns,
bridges, inlays, onlays and veneers. This exclusion does not
apply if the replacement is necessary because of extraction of
a functioning natural tooth; or a present crown, bridge, or
denture is temporary and a permanent crown, bridge or
denture is installed within 12 months from the date the
temporary service was installed.
D. Replacement of crowns, bridges, dentures and fixed or
removable prosthetic appliances, implants, implant crowns,
implant prosthesis and implant supporting structures (such as
connectors), inserted prior to plan coverage unless the
covered person has been insured under the plan for 12
continuous months. If loss of a tooth requires the addition of a
clasp, pontic, and/or abutment(s) within this 12-month period,
dental services associated with the addition will be covered
when the service is a covered expense.
E. Replacement of complete dentures, fixed and removable
partial dentures or crowns, implants, implant crowns, implant
prosthesis and implant supporting structures (such as
connectors), if damage or breakage was directly related to
provider error. This type of replacement is the responsibility of
the dentist. If replacement is necessary because of the
covered person’s non-compliance, the covered person is
liable for the cost of the replacement.
Definitions
“Grievance” means any dissatisfaction with us offering a health
benefit plan or administration of a health benefit plan by us that
is expressed in writing in any form to us by, or on behalf of, a
covered person including, but not limited to, any of the following:
A. Provision of services.
B. Determination to reform or rescind a policy.
C. Claims practices.
Term of Coverage and Renewability
The policy term begins as of the effective date of the policy. You
may keep the policy in force by paying us the required premium
as it comes due. However, we may cancel the policy if there is
fraud or material misrepresentation made by or with the
knowledge of a covered person in filing a claim.
Premium
From time to time, we may change the rate table used for this
policy form. Each premium will be based on the rate table in
effect on that premium’s due date. The type and level of benefits
and place of residence on the premium due date are some of
the factors that could be used in determining your premium
rates. At least 60-days written notice of any plan to take an
action or make a change permitted by this clause will be mailed
to you at your last address as shown in our records. We will
make no change in your premium solely because of claims
made under this policy or a change in a covered person’s health.
Jul 26 2019 10:17:41 am
California Nondiscrimination Notice and Access to Communication Services
Golden Rule Insurance Company does not exclude, deny covered health care benefits to or
otherwise discriminate against any member on the ground of race, color, national origin,
ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or
disability for participation in or receipt of the covered health care services under any of its health
plans, whether carried out by Golden Rule Insurance Company directly or through a Network
Medical Group or any other entity with which Golden Rule Insurance Company arranges to carry
out covered health care services under any of its health plans.
Free services are available to help you communicate with us. Such as letters in other languages
or in other formats like large print. Or you can ask for an interpreter at no charge. To ask for
help, please call the toll-free number (800) 657-8205. TTY 711
If you think you weren’t treated fairly because of your sex, age, race, color, national origin, or
disability, you can send a complaint to:
Grievance Administrator
PO Box 31371
Salt Lake City UT 84131-0371
Fax: 801-478-5463
Phone: 800-657-8205
uhoappealsandgrievances@uhc.com
You must send the complaint within 60 days of when you found out about it. A decision will be
sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look
at it again. If you need help with your complaint, please call the toll-free number listed on your
health plan ID card.
You can also file a complaint with the U.S. Dept. of Health and Human Services.
Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)
Mail: U.S. Dept. of Health and Human Services
200 Independence Avenue, SW Room 509F, HHH Building
Washington, D.C. 20201
45642-G-1118
Jul 26 2019 10:17:41 am
1 11/18
California Language Assistance Notice
English
IMPORTANT LANGUAGE INFORMATION:
You may be entitled to the rights and services below. You can get an interpreter or translation
services at no charge. Written information may also be available in some languages at no charge.
To get help in your language, please call your health plan at: Golden Rule Insurance Company
1-800-657-8205 / TTY: 711.
Spanish
INFORMACIÓN IMPORTANTE DEL LENGUAJE:
Puede tener derecho a los derechos y servicios a continuación. Puede obtener un intérprete o
servicios de traducción sin cargo. La información por escrito también puede estar disponible en
algunos idiomas sin cargo. Para obtener ayuda en su idioma, llame a su plan de salud al: Golden
Rule Insurance Company 1-800-657-8205 / TTY: 711.
Chinese
重要語言信息:
您可能有權享受以下權利和服務。 您可以免費獲得口譯或翻譯服務。 書面信息也可能以某些語
免費提供。 如需獲得您的語言幫助,請致電您的健康計劃:Golden Rule Insurance Company 1-
800-657-8205 / TTY711.
Arabic
:ﺔﻐﻠﻟا نﻋ ﺔﻣﮭﻣ تﺎﻣوﻠﻌﻣ
ﻗد ﯾﺣﻖ ﻟك
اﻟﺣﺻول ﻋﻠﻰ اﻟﺣﻘوق واﻟﺧدﻣﺎت أدﻧﺎه. ﯾﻣﻛﻧك اﻟﺣﺻول ﻋﻠﻰ ﻣﺗرﺟم أو ﺧدﻣﺎت ﺗرﺟﻣﺔ ﺑدون ﻣﻘﺎﺑل. ﻗد ﺗﻛون اﻟﻣﻌﻠوﻣﺎت اﻟﻣﻛﺗوﺑﺔ
ﻣﺗﺎﺣﺔ أﯾﺿ
ً
ﻓﻲ ﺑﻌض اﻟﻠﻐﺎت دون ﻣﻘﺎﺑل. ﻟﻠﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة ﺑﻠﻐﺗك ، ﯾرﺟﻰ اﻻﺗﺻﺎل ﺑﺧطﺔ اﻟرﻋﺎﯾاﻟﺻﺣﯾ اﻟﺧﺎﺻﺔ ﺑك ﻋﻠﻰ اﻟﻌﻧوان
117/ TTY: 8205-657-800-1Golden Rule Insurance Company : اﻟﺗﺎﻟﻲ
Armenian
ԿԱՐԵՎՈՐ ԼԵԶՎԻ ՏԵՂԵԿՈՒԹՅՈՒՆՆԵՐ.
Դուք կարող եք իրավասվել ստորեւ նշված իրավունքներին եւ ծառայություններին: Դուք
կարող եք անվճար թարգմանիչ կամ թարգմանչական ծառայություններ ստանալ: Գրավոր
տեղեկությունները կարող են մատչելի լինել նաեւ որոշ լեզուներով անվճար: Ձեր լեզվով
օգնություն ստանալու համար խնդրում ենք զանգահարել ձեր առողջապահական ծրագիրը
`Golden Rule Insurance Company 1-800-657-8205 / TTY: 711.
Cambodian
:



 : Golden Rule
Insurance Company 1-800-657-8205 / TTY: 711.
45676-G-1118
Jul 26 2019 10:17:41 am
2 11/18
Farsi




Golden Rule Insurance Company 1-800-657-8205 / TTY: 711.
Hindi
महप भाषा जानकारी:
                  
                
     ,       : Golden Rule Insurance
Company 1-800-657-8205 / TTY: 711.
Hmong
COV LUS LUS TSEEM CEEB:
Koj tuaj yeem tsim nyog tau cov cai thiab cov kev pab hauv qab no. Koj tuaj yeem tau
txais neeg txhais lus los yog txhais lus pab dawb tsis them nyiaj. Cov ntaub ntawv sau
kuj muaj nyob rau qee hom lus dawb xwb. Xav tau kev pabcuam ntawm koj hom lus, thov
hu rau koj qhov kev npaj khomob ntawm: Golden Rule Insurance Company 1-800-657-
8205 / TTY: 711.
Japanese
重要な言語情報:
あなたは以下の権利とサービスを受ける権利があります。 通訳や翻訳サービスを無料で受ける
ことができます。 書かれた情報は、一部の言語で無償で入手できる場合もあります。 あなたの
言語で助けを得るためには、あなたの健康計画に電話してください:Golden Rule Insurance
Company 1-800-657-8205 / TTY: 711.
Korean
중요 언어 정보 :
귀하는 아래 권리 서비스를받을 자격 있습니다. 통역사 또는 번역 서비스를 무료로 받으실
있습니다. 서면 정보 일부 언어 무료로 제공 수도 있습니다. 귀하의 언어 도움을
받으려면 다음의 건강 플랜에 전화하십시오. Golden Rule Insurance Company 1-800-657-
8205 / TTY: 711..
45676-G-1118
Jul 26 2019 10:17:41 am
3 11/18
Punjabi
ਮਹੱਤਵਪੂਰਨ ਭਾਸ਼ਾ ਜਾਣਕਾਰ:
ਤੁ
ਹੇਠਾਂ ਿਦੱਤੇ ਅਿਧਕਾਰ ਅਤ ਸੇਵਾਵਾਂ ਦੇ ਹੱਕਦਾਰ ਹੋ ਸਕਦੇ ਹੋ ਤੁ
ਿਬਨਾ ਿਕਸੇ ਲਾਗਤ 'ਤੇ ੁਭ ਜਾਂ ਅਨਵਾਦ ਸੇਵਾਵਾਂ
ਪ�ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ. ਿਲਖਤੀ ਜਾਣਕਾਰੀ ਕੁ ਭਾਗੀਦਾਰਾਂ 'ਤੇ ਿਬਨਾਂ ਿਕਸੇ ਲਾਗਤ' ਤੇ ਵੀ ਉਪਲਬਧ ਹੋ ਸਕਦੀ ਹੈ. ਆਪਣੀ ਭਾਸ਼ਾ
ਿਵੱਚ ਸਹਾਇਤਾ ਪ�ਾਪਤ ਰਨ ਲਈ, ਿਕਰਪਾ ਕਰਕੇ ਆਪਣੀ ਿਸਹਤ ਯੋਜਨਾ ੂੰ ਇੱਥੇ ਕਾਲ ਕਰੋ:
Golden Rule Insurance
Company 1-800-657-8205 / TTY: 711
Russian
ВАЖНАЯ ИНФОРМАЦИЯ ЯЗЫКА:
Вы можете иметь право на права и услуги, указанные ниже. Вы можете бесплатно получить
переводчика или услуги переводчика. Письменная информация также может быть
доступна на некоторых языках бесплатно. Чтобы получить помощь на своем языке,
позвоните в свой план медицинского обслуживания по адресу:
Golden Rule Insurance
Company 1-800-657-8205 / TTY: 711
Tagalog
IMPORMASYONG IMPORMASYON SA LANGUAGE:
Maaaring may karapatan ka sa mga karapatan at serbisyo sa ibaba. Maaari kang
makakuha ng isang interpreter o mga serbisyo ng pagsasalin nang walang bayad. Ang
nakasulat na impormasyon ay maaari ding makuha sa ilang mga wika nang walang
bayad. Upang makakuha ng tulong sa iyong wika, mangyaring tawagan ang iyong
planong pangkalusugan sa: Golden Rule Insurance Company 1-800-657-8205 / TTY: 711.
Thai
อมูลภาษาส
าค :
 
  

 

 
 :
Golden Rule
Insurance Company 1-800-657-8205 / TTY: 711
Vietnamese
THÔNG TIN NGÔN NG QUAN TRNG:
Bạn có th đưc ng các quyn và dch vi đây. Quý vcó thnhn dch vphiên dch
hoc dch thut min phí. Thông tin bng văn bn cũng thcó sn bng mt sngôn ng
min phí. Đ nhn tr giúp bng ngôn ngữ của bn, vui lòng gi cho chương trình sc khe ca
bạn ti:
Golden Rule Insurance Company 1-800-657-8205 / TTY: 711
45676-G-1118
Jul 26 2019 10:17:41 am
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