Fillable Dental Premier Plans For Individuals And Families | UnitedHealthOne (United Healthcare)

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Dental Premier Plans For Individuals And Families | UnitedHealthOne (United Healthcare)

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Golden Rule Insurance Company is the underwriter of these plans.
This product is administered by Dental Benefit Providers, Inc.
Policy Forms GRI-DEN3-JR, -01 (AL), -02 (AZ), -03 (AR), -04 (CA), -05 (CO), -06 (CT), (DE), -08 (DC), -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), -28 (NH), -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), -45 (VA), -47 (WV), and -48 (WI); GRI-DEN3-JR-PB, -11 (ID),
-34 (OH), -46 (WA); GRI-DEN3-JR-PBM, -11 (ID), -34 (OH), -46 (WA); GRI-DEN3-JR-PBM-IO-46 (WA)
1
Premier Choice and Premier Plus are the only plans available in ME.
2
The optional vision benefit is not available in MN, RI or WA.
Table of Contents
Why Dental Premier? 2
Dental Premier Choice & Elite 3
Dental Premier Plus & Max 4
Hearing Discounts 5
Optional Vision Benefits 6
Exclusions & Limitations 7
Notice of Privacy Practices 11
Dental Premier Plans
4 Plans
1
for Individuals & Families
with Optional Vision Benefits
2
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.
45586C1CA-G-0821 (includes: 45586-G-0821 and 45586iCA-G-0621)
Jul 23 2021 07:03:21 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 Premier 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. UnitedHealthcare
Hearing provides access to discounts on hearing
exams and hearing aids. See page 5 for details.
* Hearing discounts
are provided by
UnitedHealthcare
Hearing 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 Premier plans cover
preventive routine exams at 100%
starting day one. See pages 3 and
4 for details.
(Back to cover)
2 of 14
Jul 23 2021 07:03:21 am
All plans pay non-network provider benefits based on the network negotiated rate. Non-network dentists can bill a patient for any remaining amount up to the billed charge.
Premier Choice
Designed to offer immediate coverage
1
and
network discounts for preventive care, basic
and major services.
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
NO WAITING PERIODS
PREVENTIVE CARE
3 of 14
ACCESS TO DISCOUNTS
ON HEARING AIDS
Lower Premium
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 & bridges)
Policy pays 10% day one
1
40% after policy year one
1
50% after policy year two
Coverage Amount
(per calendar year)
$1,500 annual maximum
Deductible
(per calendar year, family max
3 deductibles per service type)
$50 per person
(combined basic & major services)
Most Valuable Feature No Waiting Periods
1
Premier Elite
This plan pays more for major services after a
6-month waiting period. There is no waiting
period for preventive care or basic services.
Higher Level Benefit
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 & bridges)
Policy pays 15% after
1
6-month waiting period
50% after policy year one
60% after policy year two
Coverage Amount
(per calendar year)
$2,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles per service type)
$50 per person
(combined basic & major services)
Most Valuable Feature Higher Major Services coinsurance
1
In CT and IL, after a 6-month waiting period,
major services pays 50% and remains 50%
after year one.
2
Service pricing in ZIP Code
752-- and assumes any plan waiting periods
and deductibles have been met. Discounts
vary by policy year, type of provider,
geographic area, and type of service.
Network Pricing
Over Time
2
Retail
charge
During
policy year:
Premier Choice Premier Elite
year one year two year one year two
Simple Filling $181.14
You pay:
$28.50 $19.95 $28.50 $19.95
Molar Root Canal $1,255.36
You pay:
$512.10 $341.40 $483.65 $284.50
$0
Routine Cleaning
(Network, day one)
Retail Charge for adult
without plan: $95.47
ALL PLANS
Jul 23 2021 07:03:21 am
Premier Plus
With orthodontic care for dependents plus
coverage for dental implants under Major
Services, this is our most comprehensive plan.
Premier Max
This plans offers our highest annual maximum
of $3,000, plus there is no waiting period or
deductible for preventive care.
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
1
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals, oral
surgery, bridges &
dental implants)
Policy pays 10% day one
1
40% after policy year one
1
50% after policy year two
Orthodontic Services
(additional $150 lifetime deductible,
dependents under age 19 only)
Policy pays 50% after
12-month waiting period & deductible
$1,000 Lifetime Maximum
Coverage Amount
(per calendar year)
$2,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles per service type)
$50 per person
(combined basic & major services)
Most Valuable Feature Most Diverse Coverage
OPTION TO ADD
VISION BENEFIT
NO WAITING PERIODS
PREVENTIVE CARE
4 of 14
ACCESS TO DISCOUNTS
ON HEARING AIDS
Adds Orthodontics & Dental Implants Highest Annual Maximum
Preventive Care Services
(includes routine cleaning & exams)
Policy pays 100% day one
After Deductible:
Basic Services
(includes simple fillings & extractions)
Policy pays 50% after
4-month waiting period
2
65% after policy year one
80% after policy year two
Major Services
(includes crowns, root canals,
oral surgery & bridges)
Policy pays 50% after
12-month waiting period
60% after policy year two
Coverage Amount
(per calendar year)
$3,000 annual maximum
Deductible
(per calendar year, family max
3 deductibles per service type)
$50 per person
(combined basic & major services)
Most Valuable Feature Highest Annual Maximum
1
In CT and IL: Basic services pays 50% day one. Major services pays 50%
after a 6-month waiting period and remains 50% after year one.
2
In PA, basic
services pays 35% day one.
3
Service pricing in ZIP Code 752-- and assumes
any plan waiting periods and the deductible have been met. Discounts vary
by policy year, type of provider, geographic area, and type of service.
4
On
Premier Max, major services have a 12-month waiting period.
Network Pricing
Over Time
3
Retail
charge
During
policy year:
Premier Plus Premier Max
year one year two year one year two
Molar Root Canal $1,255.36
You pay:
$512.10 $341.40 $1,255.36
4
$284.50
Surgical Implant $2,131.63
You pay:
$972.00 $648.00 Not covered
All plans pay non-network provider benefits based on the network negotiated rate. Non-network dentists can bill a patient for any remaining amount up to the billed charge.
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
Jul 23 2021 07:03:21 am
65% of people
with hearing loss are
younger than age 65.
—
betterhearing.org
The Better Hearing Institute, 2018
5 of 14
Hearing Discount Example
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 UnitedHealthcare Hearing.
ACCESS TO DISCOUNTS
ON HEARING AIDS
The people and events depicted here are fictional and do not represent actual cases.
UnitedHealthcare Hearing
KEY FEATURES
Over 5,000 hearing providers nationwide
3
Hearing exams and hearing aid evaluations
Name-brand and private-labeled hearing aids
Order hearing aids in person or through home
delivery
Limited discounts available. Administered by UnitedHealthcare Hearing.
By calling toll free at 1-855-523-9355, TTY 711, UnitedHealthcare Hearing
can guide you through the process, handling the audiologist referral so you
don’t have to see your primary care physician first
.
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
UnitedHealthcare Hearing to schedule the hearing exam. After being
diagnosed with some hearing loss, UnitedHealthcare Hearing calls Jen
to discuss the different hearing aid options available. She is able to find
hearing aids for less than retail with UnitedHealthcare Hearing’s help.
Learn more about UnitedHealthcare Hearing discounts: uhchearing.com
1
5 Ways Better Hearing Can Help Your Career, audiologyinc.net, October 2017
2
Regular Screenings are Important hearingofamerica.com, May 2017
3
2019 UnitedHealthcare internal data.
Jul 23 2021 07:03:21 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.
4
If you choose disposable contacts, up to 6 boxes are included when obtained from an
in-network provider.
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
The 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 who’s 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
4
:
$0 Copay
Non-Selection Contacts:
Any charge over $150 allowance
Non-network
Any charge over $105 allowance
Jul 23 2021 07:03:21 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 children’s 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
All Plans: 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
Premier Plus Plans only
• Implants – covered under Major Services and subject to
annual maximum – 1 time per tooth per 60 months
• Orthodontic treatment (covered eligible child under the
age of 19) – subject to lifetime maximum and deductible
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 plan’s 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.
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. (For CA, see 45586iCA-G after the brochure
for state-specific details.) All services are subject to annual maximums and may
be subject to deductible and coinsurance.
Basic Policy Details
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Idaho
Hawaii
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
7 of 14
Jul 23 2021 07:03:21 am
Misstatement of Age
If the covered person’s age has been misstated on the
covered person’s 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 person’s
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.
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.
• 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.
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
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Idaho
Hawaii
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
8 of 14
Jul 23 2021 07:03:21 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:
• Telephone consultations or for failure to keep a scheduled
appointment.
• 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. (does not apply in VA)
• 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. (Does not apply
in TX. Does not apply in SD if household member is only
provider in 50 mile radius. Someone who ordinarily
resides with a covered person does not apply in VA.)
• 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, unless included in your plan.
• 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).
• 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.
• 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
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Idaho
Hawaii
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
Minnesota
Mississippi
Missouri
Nebraska
New Hampshire
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
9 of 14
Jul 23 2021 07:03:21 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 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
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of
Columbia
Florida
Georgia
Idaho
Hawaii
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Michigan
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Jul 23 2021 07:03:21 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 individual’s 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 23 2021 07:03:21 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.
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Jul 23 2021 07:03:21 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 23 2021 07:03:21 am
Top Dental Insurance Questions
© 2021 United HealthCare Services, Inc.
45586-G-0821
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 23 2021 07:03:21 am
• Eligible dependent is expanded to include an eligible child
over age 26 if he/she is: not capable of self-sustaining
employment due to mental or physical handicap that
began before the age limit was reached; and mainly
dependent on you for support.
• The exclusion does not apply for 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.
• The exclusion does not apply for charges payable under a
medical policy issued by us.
California Dental Variations
Please see below for applicable state-specific benefits, exclusions, and limitations.
This insert must be used with our vision brochure for individual coverage (45586-G).
1 of 1
© 2021 United HealthCare Services, Inc.
45586iCA-G-0621
The ratio of incurred claims to earned premiums (loss ratio) for total accident and health for Golden Rule Insurance
Company in all states in 2020 was 58.9%.
Jul 23 2021 07:03:21 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 23 2021 07:03:21 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言
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 / TTY：711.
Arabic
:ﺔﻐﻠﻟا نﻋ ﺔﻣﮭﻣ تﺎﻣوﻠﻌﻣ
ﻗد ﯾﺣﻖ ﻟ
ك اﻟﺣﺻول ﻋﻠﻰ اﻟﺣﻘوق واﻟﺧدﻣﺎت أدﻧﺎه. ﯾﻣﻛﻧك اﻟﺣﺻول ﻋﻠﻰ ﻣﺗرﺟم أو ﺧدﻣﺎت ﺗرﺟﻣﺔ ﺑدون ﻣﻘﺎﺑل. ﻗد ﺗﻛون اﻟﻣﻌﻠوﻣﺎت اﻟﻣﻛﺗوﺑﺔ
ﻣﺗﺎﺣﺔ أﯾﺿ
ً
ﺎ ﻓﻲ ﺑﻌض اﻟﻠﻐﺎت دون ﻣﻘﺎﺑل. ﻟﻠﺣﺻول ﻋﻠﻰ اﻟﻣﺳﺎﻋدة ﺑﻠﻐﺗك ، ﯾرﺟﻰ اﻻﺗﺻﺎل ﺑﺧطﺔ اﻟرﻋﺎﯾﺔ اﻟﺻﺣﯾﺔ 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 23 2021 07:03:21 am
2 11/18
Farsi




Golden Rule Insurance Company 1-800-657-8205 / TTY: 711.
Hindi
महपूण 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
중요한 언어 정보 :
귀하는 아래 권리와 서비스를받을 자격이 있습니다. 통역사 또는 번역 서비스를 무료로 받으실
수 있습니다. 서면 정보는 일부 언어로 무료로 제공 될 수도 있습니다. 귀하의 언어로 도움을
받으려면 다음의 건강 플랜에 전화하십시오. Golden Rule Insurance Company 1-800-657-
8205 / TTY: 711..
45676-G-1118
Jul 23 2021 07:03:21 am
3 11/18
Punjabi
ਮਹੱਤਵਪੂਰਨ ਭਾਸ਼ਾ ਜਾਣਕਾਰੀ:
ਤੁਸੀ
ਂ
ਹੇਠਾਂ ਿਦੱਤੇ ਅਿਧਕਾਰ ਅਤੇ ਸੇਵਾਵਾਂ ਦੇ ਹੱਕਦਾਰ ਹੋ ਸਕਦੇ ਹੋ ਤੁਸੀ
ਂ
ਿਬਨਾ ਿਕਸੇ ਲਾਗਤ 'ਤੇ ਦੁਭਾਸ਼ੀਆ ਜਾਂ ਅਨੁਵਾਦ ਸੇਵਾਵਾਂ
ਪ�ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ. ਿਲਖਤੀ ਜਾਣਕਾਰੀ ਕੁਝ ਭਾਗੀਦਾਰਾਂ 'ਤੇ ਿਬਨਾਂ ਿਕਸੇ ਲਾਗਤ' ਤੇ ਵੀ ਉਪਲਬਧ ਹੋ ਸਕਦੀ ਹੈ. ਆਪਣੀ ਭਾਸ਼ਾ
ਿਵੱਚ ਸਹਾਇਤਾ ਪ�ਾਪਤ ਕਰਨ ਲਈ, ਿਕਰਪਾ ਕਰਕੇ ਆਪਣੀ ਿਸਹਤ ਯੋਜਨਾ ਨੂੰ 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
ข้อมูลภาษาส
ํ
าค ัญ:
 
 



 
 :
Golden Rule
Insurance Company 1-800-657-8205 / TTY: 711
Vietnamese
THÔNG TIN NGÔN NGỮ QUAN TRỌNG:
Bạn có thể được hưởng các quyền và dịch vụ dưới đây. Quý vị có thể nhận dịch vụ phiên dịch
hoặc dịch thuật miễn phí. Thông tin bằng văn bản cũng có thể có sẵn bằng một số ngôn ngữ
miễn phí. Để nhận trợ giúp bằng ngôn ngữ của bạn, vui lòng gọi cho chương trình sức khỏe của
bạn tại:
Golden Rule Insurance Company 1-800-657-8205 / TTY: 711
45676-G-1118
Jul 23 2021 07:03:21 am
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