Fill - Free fillable Short Term Medical Plans (United Healthcare) PDF form

Health insurance

available only to

members of FACT.

These health insurance plans are

issued as association group plans

and available only to members of

FACT, the Federation of American

Consumers and Travelers. Golden

Rule Insurance Company is the

underwriter and administrator of

these plans. See last page for more

details.

Certificate Forms C-016.1 and other state

variations; Certificate Form GRI-STAG16-C-EPO-42

and other state variations

Table of Contents

Understanding Short Term 2

Medical Plans

Plan Grid Comparisons 3

Optional Benefits 5

Network 6

Medical Benefits 7

State Variations 9

Exclusions & Limitations 13

Plan Provisions 15

Notice of Privacy Practices 16

Who We Are 19

Short Term Medical Plans

In times of transition and change

States:

FL IL IN MI MS

NE PA TN TX WV

This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care

Act. Be sure to check your certificate carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting

conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health

and substance use disorder services). Your certificate might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires

or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.

INTERNET/FMO

Jun 25 2020 12:01:51 pm

Short Term Medical

Understanding How it Works

Top Questions

Why should I consider this coverage?

These plans can help bridge the gap

in coverage if you: (a) must wait until

the next Open Enrollment or are

waiting for other coverage to begin;

(b) are between jobs; (c) retired early;

or (d) just graduated college. Keep in

mind that you may owe an additional

payment on your taxes because these

plans are not ACA-compliant.

Is there someplace I can view and

keep track of my benefits? Yes, with

myUHOne.com you’ll have access to

your plan benefits and the ability to

track your claims online. This member

site also allows you to search for

providers in your network and print

copies of your ID card and certificate.

A Choice of Coverage to Fit Your Specific Needs

You select the coverage term length (minimum of 30 days in most

states; maximum term length varies*), then choose your deductible,

and coinsurance that fit your budget. See pages 3-4 for a comparison

of the plans available. Once you meet your deductible, you pay a

percentage of covered expenses (coinsurance) to the coinsurance out-

of-pocket maximum amount you selected. Then insurance pays 100%

of the remaining covered expenses to the lifetime maximum benefit.

UnitedHealthCare Choice Network Advantages

Receive quality care at reduced costs because the network providers

have agreed to lower fees for covered expenses. The large network of

doctors and hospitals offer choices across the nation, so even when

you’re traveling, you’re likely to find in-network care. You must use a

network doctor or hospital. These plans pay no benefits for

out-of-network expenses except for emergencies. See page 6 for

more details.

* See State Variations for term lengths available in your state.

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, see State Variations. Short Term

Medical plans do not provide coverage for preexisting conditions and are

subject to medical underwriting.

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(Back to Cover)

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Highlights of Network Covered Expenses

(per covered person, per term)

Highlights of Covered Expenses

Network Expenses Only - Per Covered Person, Per Term

You must use a network doctor or hospital with these plans. No benefits will be paid for

expenses from a non-network provider except for emergencies. See page 6.

Short Term Medical Plans: Value Select Plus Select Copay Select Plus Elite

Coverage Term Length

Choose length: See State Variations for term lengths available in your state.

Deductible Type

Per Term (One deductible for selected length of coverage)

Deductible Amount

(per person)

You pay

up to:

Choose $1,000

, $2,500, $5,000, $10,000, or $12,500

Option:

Add Supplemental

Accident Beneﬁt

We pay

up to:

$1,000

, $2,500, $5,000, $10,000, or $12,500

(Choose any amount to help cover your expenses in the case of an accident.)

Coinsurance

(% of covered

expenses you pay after deductible)

You pay:

Choose 30% or 40% Choose 20% or 40% 20% 0%

Coinsurance Out-of-pocket

Maximum

(after deductible,

per person, copays not included)

You pay

up to:

Choose $5,000

or $10,000

Choose $2,000, $5,000

or $10,000

$5,000 $0

Lifetime Maximum Beneﬁt we will pay (per person):

$600,000 on these plans

Doctor Visits

Doctor Oﬃce Visit, History,

and Exam only

You

pay:

Chosen coinsurance

after deductible

Chosen coinsurance

after deductible

$50 copay

Coinsurance after

deductible

Urgent Care Center

$75 copay

Outpatient

Emergency Room

You

pay:

$250 copay, then subject to deductible and coinsurance.

Outpatient Surgery, Labs,

X-rays, and PSA Screening

Coinsurance after deductible

Inpatient

Hospital Services

You

pay:

Coinsurance after deductible

Pharmacy

Prescription (Rx) Drugs

($3,000 max benet)

Not covered.

Discount Card only

Preferred Price Card & coinsurance after deductible

You pay for prescriptions at the point of sale, at the lowest price

available, and submit a claim to us with the Preferred Price Card.

Once your plan deductible is met, you then pay only your coinsurance.

These plans are not available in Indiana.

$1,000 option not available with the Plus Elite plan.

Expenses for injuries are eligible for coverage as of your plan’s eective date; expenses for illnesses are eligible for coverage

beginning on the 6th day following the eective date.

Number of visits subject to copay varies by coverage term length. Additional visits subject to deductible and coinsurance. See page 7.

Discount card can help you save an average of 20-25% on your Rx drugs. Discounts vary by pharmacy, geographic area, and drug.

Jun 25 2020 12:01:51 pm

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Highlights of Network Covered Expenses

(per covered person, per term)

Short Term Medical Plans: Value Select A Plus Select A Copay Select A Plus Elite A

Coverage Term Length

Choose length: See State Variations for term lengths available in your state.

Deductible Type

Per Term (One deductible for selected length of coverage)

Deductible Amount

(per person)

You pay

up to:

Choose $1,000

, $2,500, $5,000, $10,000, or $12,500

Option:

Add Supplemental

Accident Beneﬁt

We pay

up to:

$1,000

, $2,500, $5,000, $10,000, or $12,500

(Choose any amount to help cover your expenses in the case of an accident.)

Coinsurance

(% of covered

expenses you pay after deductible)

You pay:

Choose 30% or 40% Choose 20% or 40% 20% 0%

Coinsurance Out-of-pocket

Maximum

(after deductible,

per person, copays not included)

You pay

up to:

Choose $5,000

or $10,000

Choose $2,000, $5,000

or $10,000

$5,000 $0

Doctor Visits

Doctor Oﬃce Visit, History,

and Exam only

You

pay:

Chosen coinsurance

after deductible

Chosen coinsurance

after deductible

$50 copay

Coinsurance after

deductible

Urgent Care Center

$75 copay

Outpatient

Emergency Room

You

pay:

$250 copay, then subject to deductible and coinsurance.

Outpatient Surgery, Labs,

X-rays, and PSA Screening

Coinsurance after deductible

Inpatient

Hospital Services

You

pay:

Coinsurance after deductible

Pharmacy

Prescription (Rx) Drugs

($3,000 max benet)

Not covered.

Discount Card only

Preferred Price Card & coinsurance after deductible

You pay for prescriptions at the point of sale, at the lowest price

available, and submit a claim to us with the Preferred Price Card.

Once your plan deductible is met, you then pay only your coinsurance.

$2 million annual maximum in Indiana.

$1,000 option not available with the Plus Elite A plan.

Expenses for injuries are eligible for coverage as of your plan’s eective date; expenses for illnesses are eligible for coverage

beginning on the 6th day following the eective date.

Number of visits subject to copay varies by coverage term length. Additional visits subject to deductible and coinsurance. See page 7.

Discount card can help you save an average of 20-25% on your Rx drugs. Discounts vary by pharmacy, geographic area, and drug.

Lifetime Maximum Beneﬁt

we will pay (per person):

$2 million on these plans

Highlights of Covered Expenses

Network Expenses Only - Per Covered Person, Per Term

You must use a network doctor or hospital with these plans. No benefits will be paid for

expenses from a non-network provider except for emergencies. See page 6.

Jun 25 2020 12:01:51 pm

Optional Benefit

Available for additional premium on all plans.

Supplemental Accident Optional Benefit

Certificate Form 6-C-410

Reduce or eliminate your out-of-pocket exposure for accident-related injuries

for additional premium. Supplemental Accident helps cover your deductible

or other out-of-pocket medical expenses (before the health insurance starts

paying covered expenses) for unexpected injuries. You select a maximum

amount ($1,000,* $2,500, $5,000, $10,000 or $12,500) per accident, per

covered person.

* Note: The $1,000 benefit amount is not an option with the Short Term

Medical Plus Elite and Plus Elite A plans.

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ALABAMA

ARKANSAS

NORTH CAROLINA

OHIO

OKLAHOMA

Choice Network States

Short Term Medical

All of our plans use a network of doctors, hospitals, and other providers that offer you

quality health care.

Visit UHOne.com and select Find A Doctor to search for

UnitedHealthcare

Choice network providers.

These plans only pay benefits for eligible expenses from a network provider. No benefits

are payable for non-emergency care from a non-network provider. Emergency

treatment from a non-network provider will be treated as a network eligible service.

UnitedHealth Group Annual Form 10-K for year ended 12/31/19.

Access to Quality Care from:

• Any network specialist without

needing a referral.

• 1.4 million physicians and other

health care professionals.

• More than 6,500 hospitals and

other facilities.

No Balance Billing

Our network providers will

not balance bill you for

eligible expenses. Health care

professionals in the network

agree to provide you quality

care at lower fees.

Nationwide Network

Use any doctor in the Choice

network across the nation.

No Primary Care Physician

(PCP) required. Note: There

e no non-network benefits.

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Jun 25 2020 12:01:51 pm

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Medical Benefits (all plans)

Ambulance Services

Ground ambulance service to a hospital for necessary

emergency care.

Autism Spectrum Disorders

Outpatient applied behavior analysis limited to $50,000 per

policy term, per covered person.

Dental Services

Dental expenses for an injury to natural teeth suffered after

the coverage effective date. Expenses must be

incurred within 6 months of the accident.

o beneﬁts payable for injuries due to chewing as

limited in the policy.

Diabetes

• Diabetes equipment, supplies, and services.

• Diabetes self-management training when medically

necessary as determined by a physician, prescribed by

a physician, and provided by an appropriately licensed

alth care professional limited to:

- One diabetes self-management training program per

covered person, per lifetime.

- Additional diabetes self-management training

prescribed by a physician as medically necessary due

to a significant change in the covered person’s

symptoms or condition.

Diagnostic Testing

Doctor Oce Visit Copay (History and Exam only)

Only available with Copay Select and Copay Select A plans.

Available doctor office visits: 1 copay for 30-90 day term,

2 copays for 91-180 day term, or 3 copays for 181+ day term.

dditional visits subject to deductible and coinsurance.

Coverage term lengths available vary by state.

Durable Medical Equipment

Rental of wheelchair, hospital bed, and other durable

medical equipment.

Home Health Care

Home health care prescribed and supervised by a doctor

and provided by a licensed home health care agency.

Covered expenses for home health aide services will be

limited to 7 visits per week and a lifetime maximum of 365

visits. Benefits for home health care will not extend beyond

the term of your plan. Each 8-hour period of home health

aide services will be counted as one visit. Private duty

registered nurse services will be limited to a lifetime

maximum of 1,000 hours. Intermittent private duty registered

nurse visits are not to exceed 4 hours each and are limited

to $75 per visit (2 hours per visit are applied toward the

lifetime maximum of registered nursing).

No beneﬁts payable for respite care, custodial care, or

educational care.

Hospital Services

Daily hospital room and board at most common semiprivate

rate; eligible expenses for an intensive care unit; inpatient

use of an operating, treatment, or recovery room; outpatient

use of an operating, treatment, or recovery room for surgery;

services and supplies, including drugs and medicines,

which are routinely provided in the hospital to persons for

use only while they are inpatients; emergency treatment of

an injury or illness. Covered expenses for use of the

emergency room are subject to a copayment of $250 for

each emergency room visit.

Hospital does not include a nursing or convalescent home

or an extended care facility.

Medical Supplies

• Dressings and other necessary medical supplies.

• Cost and administration of an anesthetic or oxygen.

The following medical benefits are provided using network providers and are subject to all policy provisions,

the deductible, and any applicable copay or coinsurance (unless otherwise stated). You will find complete

coverage details in the policy. See state variations for differences in the standard benefits below.

Jun 25 2020 12:01:51 pm

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Newborn Care

• Routine in-hospital care of a newborn for the first five days

or until the mother is released which ever occurs first.

• Pregnancy not covered, except for complications.

Outpatient Surgery

Physician Fees

• Professional fees of doctors, medical practitioners,

and surgeons.

• Assistant surgeon fee for a doctor, limited to 20% of

eligible expenses of the procedure, and 14% of eligible

expenses of the procedure for another medical

professional acting as an assistant surgeon.

Preventive Care

• Children’s preventive health services for covered children

as defined in the certificate.

• Colorectal cancer examinations, prostate-specific antigen

testing, and other preventive care as required by your

state and specified in the certificate.

Rehabilitation and Extended Care Facility (ECF)

Must begin within 14 days of a 3-day or longer hospital stay

for the same illness or injury. Limited to 60 days per policy

term for both rehabilitation and ECF expenses

Spine and Back Disorders

Benefits for treatment of spine and back disorders limited to

$250 per person, per policy term.

Therapeutic Treatments

• Radiation therapy and chemotherapy.

• Hemodialysis, processing, and administration of blood or

components (but not the cost of the actual blood or

components).

Transplant Expense Benet

The following transplants are covered the same as any

other illness: cornea, artery or vein grafts, heart valve

grafts, prosthetic tissue and joint replacement, and

prosthetic lenses for cataracts.

For all other covered transplants, see your certificate for

“Listed Transplants” under Transplant Expense Benefits.

The covered person must be a good candidate, as

etermined by us. The transplant must not be experimental

or investigational. Covered expenses for “Listed Transplants”

are limited to 2 transplants per policy term, per covered person.

olden Rule has arranged for certain hospitals around the

country (“Centers of Excellence”) to perform specified

transplant services. If you use one of our “Centers of

Excellence,” the specified transplant will be considered the

same as any other illness and will include transportation and

lodging incentive (for a family member) of up to $5,000. If a

“Center of Excellence” is not used, covered expenses for

the “Listed Transplant” will be limited to one transplant in

any 12-month period with a maximum benefit of $100,000 for

all expenses associated with the transplant.

If a “Center of Excellence” is not used, the acquisition cost for

the organ or bone marrow is not covered.

No beneﬁts payable for:

• Search and testing in order to locate a suitable donor.

• A prophylactic bone harvest and peripheral blood stem

cell collection when no “listed transplant” occurs.

• Animal-to-human transplants.

• Artificial or mechanical devices designed to replace a

human organ temporarily or permanently.

• Procurement or transportation of the organ or tissue,

unless expressly provided in this provision.

• Keeping a donor alive for the transplant operation.

• A live donor where the live donor is receiving a

transplanted organ to replace the donated organ.

• A transplant under study in an ongoing Phase I or II

clinical trial as set forth in the USFDA regulation.

Medical Benefits, continued (all plans)

Jun 25 2020 12:01:51 pm

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ALABAMA

ARKANSAS

NORTH CAROLINA

OHIO

OKLAHOMA

State Variations

Short Term Medical

Please see below for state availability

and applicable state-specific benefits,

exclusions, and limitations.

Florida Certicate Form C-016.1-09

• Coverage term length: 30-360 days.

• An unmarried, eligible child may remain covered through

age 30.

• Routine follow-up care to determine whether a breast

cancer has recurred in a person who has been previously

determined to be free of breast cancer does not

constitute medical advice, diagnosis, care or treatment for

purposes of determining preexisting conditions unless

evidence of breast cancer is found during or as a result of

the follow-up care.

• Transportation charges for a newborn to and from the

nearest appropriate facility for medically necessary care

limited to a maximum of $1,000.

• Covered expenses are expanded to include:

- General anesthesia and services at a hospital or

outpatient surgical facility for necessary dental care for

an eligible child: less than 8 years old with a significantly

complex dental condition or development disability for

which treatment in a dental office would be ineffective;

or who has one or more medical conditions that create

a significant or undue risk if the necessary dental care

was not performed in a hospital or outpatient surgical

center.

- Medically necessary services and treatment for cleft lip

and palate for an eligible child under age 18.

- Diagnostic or surgical procedures involving bones or

joints of the jaw and facial region, if under accepted

medical standards, the procedure or surgery is

medically necessary to treat conditions caused by

congenital or developmental deformity, disease, or

injury.

Illinois Certicate Form C-016.1

• Coverage term length: 30-180 days.

• The definition of an eligible child is expanded to include

an unmarried dependent under 30 years of age who: (a)

Is an Illinois resident; (b) has served in the U.S. Armed

Forces; (c) received a release or discharge other than

dishonorable; and (d) has submitted a copy of a DD2-14

Certificate of Release or Discharge from active duty.

• The definition of “spouse” is expanded to include civil

union partner.

• Covered expenses are expanded to include:

- Inpatient treatment of alcoholism.

- One pap smear each calendar year.

- Surveillance test for ovarian cancer for covered females

at risk.

- One annual FDA-approved screening for human

papillomavirus. The cost and administration of

FDA-approved human papillomavirus vaccine.

- Habilitative services for covered persons under age 19

diagnosed with a congenital, genetic, or early acquired

syndrome. Treatment must be from licensed practitioners.

- Medically necessary amino acid-based elemental

formulas for the treatment of eosinophilic disorders or

short bowel syndrome.

- FDA-approved shingles vaccine, ordered by a doctor for

persons age 60 and older.

- Pain medication and therapy related to treatment of

breast cancer to the same extent as any other illness.

- Routine patient care incurred by a covered person in a

qualified cancer trial to the same extent as coverage for

routine patient care for a covered person not enrolled in

a qualified clinical cancer trial. Specific details included

in the certificate.

- For a female covered person, one clinical breast exam

per calendar year.

- Breast cancer screening (exempt from deductible,

copayments, coinsurance, when provided by a network

provider) limited to: one routine mammography exam

per calendar year for each female covered person;

additional mammograms at medically necessary intervals;

and a comprehensive ultrasound when a mammogram

shows heterogeneous or dense breast tissue.

- Contraceptive services including: drugs, devices and

products approved by the FDA. (Exempt from deductible,

copayments, coinsurance, when provided by a network

provider).

• General exclusions and limitations are modified as

follows: Covered expenses will not include, and no

benefits will be paid for charges incurred for modification

of the physical body in order to improve the psychological,

mental, or emotional well-being of the covered person,

except for charges for sex-change surgery or any other

surgical or non-surgical treatment of gender dysphoria or

gender identity disorder will be a covered expense,

subject to all other limitations and exclusions of the

certificate.

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State Variations, continued

Short Term Medical

Please see below for state availability and applicable state-specific benefits, exclusions, and limitations.

Illinois, continued Certicate Form C-016.1

• The definition of emergency is deleted and replaced with the

following: “Emergency” means a medical condition manifesting

itself by acute symptoms of sufficient severity, including, but

not limited to, severe pain, or by acute symptoms developing

from a chronic medical condition that would lead a prudent

layperson, possessing an average knowledge of health and

medicine, to reasonably expect the absence of immediate

medical attention to result in any of the following: (a) Placing

the health of an individual, or with respect to a pregnant

woman, the health of the woman or her unborn child, in

serious jeopardy; (b) Serious impairment to bodily functions;

or (c) Serious dysfunction of any bodily organ or part.

• NOTICE: THE SHORT-TERM, LIMITED-

DURATION INSURANCE BENEFITS UNDER

THIS COVERAGE DO NOT MEET ALL

FEDERAL REQUIREMENTS TO QUALIFY

AS “MINIMUM ESSENTIAL COVERAGE”

FOR HEALTH INSURANCE UNDER THE

AFFORDABLE CARE ACT. THIS PLAN OF

COVERAGE DOES NOT INCLUDE ALL

ESSENTIAL HEALTH BENEFITS AS

REQUIRED BY THE AFFORDABLE CARE

ACT. PREEXISTING CONDITIONS ARE

NOT COVERED UNDER THIS PLAN OF

COVERAGE. BE SURE TO CHECK YOUR

POLICY CAREFULLY TO MAKE SURE YOU

UNDERSTAND WHAT THE POLICY DOES

AND DOES NOT COVER. IF THIS

COVERAGE EXPIRES OR YOU LOSE

ELIGIBILITY FOR THIS COVERAGE, YOU

MIGHT HAVE TO WAIT UNTIL THE NEXT

OPEN ENROLLMENT PERIOD TO GET

OTHER HEALTH INSURANCE COVERAGE.

YOU MAY BE ABLE TO GET LONGER

TERM INSURANCE THAT QUALIFIES AS

“MINIMUM ESSENTIAL COVERAGE” FOR

HEALTH INSURANCE UNDER THE

AFFORDABLE CARE ACT NOW AND HELP

TO PAY FOR IT AT WWW.HEALTHCARE.GOV.

Indiana Certicate Form C-016.1

• Coverage term length: 30-184 days.

• Application fee is refundable if coverage is not issued or

policy is returned during the Free Look period.

• The definition of preexisting condition is replaced with:

“Preexisting condition” means a condition for which the

covered person received medical advice or treatment

within the 12 months immediately preceding the date he

or she became insured under the policy.

• Only plans with $2 million annual maximum are available.

Michigan Certicate Form GRI-STAG16-C-EPO-21

• Coverage term length: 30-184 days.

• Covered expenses do not include illness or injury resulting

from a covered person attempting to or committing a

misdemeanor or felony, whether charged or not, or if a

contributing cause was the person’s illegal occupation or

willful criminal activity.

Mississippi Certicate Form C-016.1

• Coverage term length: 30-360 days.

• The definition of preexisting condition is replaced with:

“Preexisting condition” means an injury or illness for

which the covered person received medical advice,

diagnosis, care or treatment was recommended to or

received by a covered person within the 6 months

immediately preceding the applicable effective date the

covered person became insured under the certificate; or

which, in the opinion of a qualified doctor: (1) probably

began prior to the applicable effective date the covered

person became insured under the certificate; and (2)

manifested symptoms which would cause an ordinarily

prudent person to seek diagnosis or treatment within the 6

months immediately preceding the applicable effective date

the covered person became insured under the certificate.

• Covered expenses are expanded to include:

- Charges for general anesthesia and associated facility

fees incurred in conjunction with dental care (whether

or not the dental care is covered) that is provided in a

hospital or an outpatient surgical facility or dental office

to a covered person as defined in the certificate.

- Mammograms.

• Covered expenses do not include treatment of

temporomandibular joint (TMJ) disorders.

Jun 25 2020 12:01:51 pm

11 of 19

Nebraska Certicate Form C-016.1

• Coverage term length: 30-360 days.

• Mammography screenings are covered. Specific details in

the certificate.

• The definition of emergency is deleted and replaced with

the following: “Emergency” means a medical or behavioral

condition, the onset of which is sudden, that manifests itself

by acute symptoms of sufficient severity, including, but not

limited to, severe pain, or by acute symptoms developing

from a chronic medical condition that would lead a prudent

layperson, possessing an average knowledge of health and

medicine, to reasonably expect the absence of immediate

medical attention to result in any of the following:

A. Placing the health of the covered person afflicted in

serious jeopardy, or in the case of a behavioral

condition, placing the health of the person or others in

serious jeopardy;

B. Serious impairment to bodily functions; or

C. Serious impairment of any bodily organ or part.

D. Serious disfigurement of the covered person.

Pennsylvania Certicate Form GRI-STAG16-C-EPO-37R

• Coverage term length: 30-360 days.

• Childhood immunizations are exempt from any deductible

amount or maximum dollar limits but limited to 150% of

the average wholesale price of the immunizing agent as

published by the Pennsylvania Department of Health (or

as determined in good faith by us in the absence of such

publication of the average wholesale price).

• Mammograms are covered as follows: (1) A screening

mammogram annually for covered persons 40 years of

age or older; and (2) A mammogram upon the

recommendation of a physician for covered persons

under 40 years of age.

• One routine gynecological examination is covered,

including a pelvic examination and clinical breast

examination, for each female covered person each

calendar year.

• Routine pap smears are covered in accordance with

the recommendations of the American College of

bstetricians and Gynecologists.

Tennessee Certicate Form GRI-STAG16-C-EPO-41

• Coverage term length: 30-360 days.

• The $250 limit on the treatment of spine and back

disorders does not apply.

• Covered expenses are expanded to include:

- Diabetes self-management training, if certified by a

physician to be medically necessary: upon diagnosis; or

due to significant change in symptoms or condition; or

for re-education or refresher training.

- Mammography screenings as limited in the certificate.

- Hearing aids, limited to $1,000 per ear, per certificate

term for covered persons under 18 years of age.

- Surgical and non-surgical treatment for disorders of the

temporomandibular joint (TMJ) as detailed in the

certificate.

- Hospital expenses and the cost of general anesthesia

associated with any inpatient/outpatient hospital dental

procedure when the procedure is performed on a

covered person 8 years of age and younger and cannot

safely be performed in a dental office.

Texas Certicate Form GRI-STAG16-C-EPO-42

• Coverage term length: 30-360 days.

• Covered expenses are expanded to include:

- Additional diabetes services and equipment for covered

persons with elevated glucose levels, as detailed in the

certificate.

- Emergency treatment that includes a hospital

emergency room, freestanding emergency medical care

facility, or comparable facility.

- The most appropriate model of prosthetic device or

orthotic device, as detailed in the certificate.

- Diagnostic and surgical treatment of temporomandibular

joint disorders and craniomandibular joint disorders.

- Diagnosis and treatment of mental disorders and

substance abuse. This includes services received in a

psychiatric day treatment facility, a residential treatment

center for children or adolescents and a crisis

stabilization unit.

State Variations, continued

Short Term Medical

Please see below for state availability and applicable state-specific benefits, exclusions, and limitations.

Jun 25 2020 12:01:51 pm

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State Variations, continued

Short Term Medical

Please see below for state availability and applicable state-specific benefits, exclusions, and limitations.

Texas, continued Certicate Form GRI-STAG16-C-EPO-42

• Covered expenses are expanded to include:

- Medically necessary hearing aids or cochlear implants

for an eligible child up to 18 years, limited to one hearing

aid in each ear every three years and one cochlear

implant in each ear.

- Screenings for autism spectrum disorder for an eligible

child at 18 and 24 months of age.

- Generally recognized services prescribed for the

diagnosis and treatment of autism spectrum disorder for

covered persons as detailed in the certificate.

- Outpatient applied behavior analysis for the treatment of

autism spectrum disorders, limited to a maximum of

$50,000 per certificate term for covered persons 10

years of age or older.

- Additional preventive health services, as detailed in the

certificate.

• If a designated Center of Excellence is not used, covered

expenses for a listed transplant will be reduced by 25%

after application of any deductible amounts, coinsurance

provisions, or copayment amounts.

• The definition of preexisting condition is replaced with:

“Preexisting condition” means an injury or illness for

which the covered person received medical advice or

treatment within the 12 months immediately preceding

the applicable effective date the covered person became

insured under the certificate.

West Virginia Certicate Form C-016.1-47

• Coverage term length: 30-360 days.

• Covered expenses for diabetes self-management training

services are deleted and replaced with the following:

Covered expenses for diabetes self-management training

services are limited to $100 per covered person, per

calendar year.

• When determining covered expenses for dental expenses,

injury will include damage to the natural teeth incurred as

a result of chewing if the damage was caused by a

non-edible foreign object found in food.

•

Covered expenses are expanded to include:

- An annual kidney disease screening using any

combination of blood pressure testing, urine albumin or

urine protein testing as recommended by the National

Kidney Foundation.

- Charges for general anesthesia, facility fees, and other

related charges incurred in conjunction with dental care

(but not the actual dental services) that are provided in a

hospital or an outpatient surgical facility to a covered

person as defined in the certificate.

• The following cancer screenings are covered:

mammograms, pap smear, and HPV virus. Details are in

the certificate.

Jun 25 2020 12:01:51 pm

13 of 19

General Exclusions

Benefits will not be paid for services or supplies that are not

administered or ordered by a doctor and medically

necessary to the diagnosis or treatment of an illness or

injury, as defined in the policy.

No beneﬁts are payable for expenses:

• For non-emergency services or supplies received from

a provider who is not a network provider, except as

pecifically provided for by the policy.

• For a preexisting condition — A condition:

(1) for which medical advice, diagnosis, care, or treatment

as recommended or received within the 24 months

immediately preceding the date the covered person

became insured under the policy/certificate; or (2) that

had manifested itself in such a manner that would have

caused an ordinarily prudent person to seek medical

advice, diagnosis, care, or treatment within the

12 months immediately preceding the date the covered

person became insured under the policy/certificate.

• A pregnancy existing on the effective date of coverage will

also be considered a preexisting condition.

• NOTE: Even if you have had prior Golden Rule coverage

and your preexisting conditions were covered under that

plan, they will not be covered under this plan.

• That would not have been charged if you did not have

insurance.

• Incurred while your coverage is not in force.

• Imposed on you by a provider (including a hospital) that

are actually the responsibility of the provider to pay.

• For services performed by an immediate family member.

• That are not identified and included as covered expenses

under the policy/certificate or are in excess of the eligible

expenses.

• For services that are not covered expenses.

• For services or supplies that are provided prior to the

effective date or after the termination date of the

coverage.

• For weight modification or surgical treatment of obesity,

including wiring of the teeth and all forms of intestinal

bypass surgery.

• For breast reduction or augmentation.

• For drugs, treatment, or procedures that promote

conception.

• For sterilization or reversals of sterilization.

• For fetal reduction surgery or abortion (unless life of

mother would be endangered).

• For treatment of malocclusions, disorders of the

temporomandibular joint (TMJ) or craniomandibular

disorders.

• For modification of the physical body in order to improve

psychological, mental, or emotional

well-being, such as sex-change surgery.

•

Not specifically provided for in the policy, including

telephone consultations, failure to keep an appointment,

television expenses, or telephone expenses.

• For marriage, family, or child counseling.

• For standby availability of a medical practitioner when no

treatment is rendered.

• For hospital room and board and nursing services if

admitted on a Friday or Saturday, unless for an

emergency, or for medically necessary surgery that is

scheduled for the next day.

• For dental expenses, including braces and oral surgery,

except as provided for in the policy/certificate.

• For cosmetic treatment.

• For reconstructive surgery unless incidental to or following

surgery or for a covered injury, or to correct a birth defect

in a child who has been a covered person since childbirth

until the surgery.

• For diagnosis or treatment of learning disabilities,

attitudinal disorders, or disciplinary problems.

• For diagnosis or treatment of nicotine addiction.

• For charges related to, or in preparation for, tissue or

organ transplants, except as expressly provided for under

Transplant Services.

• For high-dose chemotherapy prior to, in conjunction with,

or supported by ABMT/BMT, except as specifically

provided under the Transplant Expense Benefits provision.

This is only a general outline of the coverage provisions and exclusions. It is not an insurance contract,

nor part of the insurance policy/certificate. You will find complete coverage details in the policy/certificate.

Also see state variations.

What’s not covered (all plans)

Jun 25 2020 12:01:51 pm

14 of 19

What’s not covered, continued (all plans)

General Exclusions, continued

No beneﬁts are payable for expenses:

• For eye refractive surgery, when the primary purpose is to

correct nearsightedness, farsightedness, or astigmatism.

• While confined for rehabilitation, custodial care,

educational care, nursing services, or while at a residential

treatment facility, except as provided for in the policy/

certificate.

• For eyeglasses, contact lenses, hearing aids, eye

refraction, visual therapy, or any exam or fitting related to

these devices, except as provided for in the policy/

certificate.

• Due to pregnancy (except complications), except as

provided in the policy/certificate.

• For diagnostic testing while confined primarily for

well-baby care, except as provided in the policy/certificate.

•

For treatment of mental disorders or substance abuse

including court-ordered treatment for programs, except as

provided in the policy/certificate.

• For preventive care or prophylactic care, including routine

physical examinations, premarital examinations, and

educational programs, except as provided in the policy/

certificate.

• Incurred outside of the U.S., except for emergency

treatment.

• Resulting from declared or undeclared war; intentionally

self-inflicted bodily harm (whether sane or insane); or

participation in a riot or felony (whether or not charged).

• For or related to durable medical equipment or for its

fitting, implantation, adjustment or removal or for

complications therefrom, except as provided for in the

policy/certificate.

• For outpatient prescription drugs, except as provided for

in the policy/certificate.

• For surrogate parenting

• For treatments of hyperhidrosis (excessive sweating).

• For alternative treatments, except as specifically covered

by the policy/certificate, including: acupressure,

acupuncture, aromatherapy, hypnotism, massage therapy,

rolfing, and other alternative treatments defined by the

Office of Alternative Medicine of the National Institutes of

Health.

• Resulting from or during employment for wage or profit,

if covered or required to be covered by workers’

ompensation insurance under state or federal law.

If you entered into a settlement that waives your right to

recover future medical benefits under a workers’

compensation law or insurance plan, this exclusion will

still apply.

• Resulting from intoxication, as defined by state law where

the illness or injury occurred, or while under the influence

of illegal narcotics or controlled substances, unless

administered or prescribed by a doctor.

• For joint replacement, unless related to an injury covered

by the policy/certificate.

• For non-emergency treatment of tonsils, adenoids,

hemorrhoids or hernia.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following: sports (professional, or

semi-professional, or intercollegiate except for intramural),

parachute jumping, hang-gliding, racing or speed testing

any motorized vehicle or conveyance, scuba/skin diving

(when diving 60 or more feet in depth), skydiving, bungee

jumping, or rodeo sports.

• For injuries sustained during or due to participating,

instructing, demonstrating, guiding, or accompanying

others in any of the following if the covered person is paid

to participate or to instruct: operating or riding on a

motorcycle, racing or speed testing any non-motorized

vehicle or conveyance, horseback riding, rock or

mountain climbing, or skiing.

• For injuries sustained while performing the duties of an

aircraft crew member, including giving or receiving

training on an aircraft.

• For vocational or recreational therapy, vocational

rehabilitation, or occupational therapy, except as provided

for in the policy/certificate.

• Resulting from experimental or investigational treatments,

or unproven services.

Jun 25 2020 12:01:51 pm

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Other Details (all plans)

Coordination of Benets (including Medicare)

If after coverage is issued, a covered person becomes

insured under another health plan or Medicare, benefits will

be determined under the Coordination of Benefits (COB)

clause.

COB allows two or more plans to work together so the total

amount of all benefits is never more than 100% of covered

expenses. COB also takes into account medical coverage

under auto insurance contracts. To determine which plan is

primary, refer to “order of benefits” in the certificate.

Dependents

For purposes of this coverage, eligible dependents are your

lawful spouse and eligible children. Eligible children must be

under 26 years of age at time of application.

Eective Date

Expenses for injuries are eligible for coverage as of your

plan’s eﬀective date; expenses for illnesses are eligible

for coverage beginning on the 6th day following the

eﬀective date. Your certiﬁcate will take eﬀect on the

ter of:

• The requested effective date on your application; or

• The day after the postmark date affixed by the U.S. Postal

Service,* but only if the following conditions are satisfied:

A. Your application and the appropriate premium payment are

actually received by us within 15 days of your signing;**

B. You are a member of the Federation of American

Consumers and Travelers (FACT);

C. Your application is properly completed and unaltered;

D. You have answered “no” to question 2 (if other questions

are answered “yes,” we will exclude the person(s) listed);

E. You are a resident of a state in which the certificate form

can be issued; and

F. If the application is submitted by an agent or broker, the

agent or broker is properly licensed and appointed to

submit applications to Golden Rule.

* If mailed and not postmarked by the U.S. Postal Service or

if the postmark is not legible, the effective date will be the

later of:

(1) the date you requested; or (2) the date received by

Golden Rule. If the application is sent by any electronic

ans including fax, your coverage will take effect on the

later of: (1) the requested effective date; or (2) the day after

the date received by Golden Rule.

** Your account will be immediately charged.

Eligibility

At time of application, the primary insured must be a

minimum of 19 years of age.

Eligible Expense

An eligible expense means a covered expense as follows:

• For Network Providers: The contracted fee for the provider.

• For Non-Network Providers: As defined in the policy.

Emergency

“Emergency” means an unforeseen or sudden medical

condition manifesting itself by acute signs or symptoms

which could reasonably result in death or serious disability

if medical attention is not provided within 24 hours.

No Non-Network Benets

• These plans only pay benefits for eligible expenses

from a network provider. Visit U

HOne.com to search for

providers.

• No benefits are payable for non-emergency care from a

non-network provider.

•

Emergency treatment from a non-network provider will be

treated as a network eligible service. This means you will

owe the difference between what the non-network provider

bills and what we pay for a network eligible expense.

Non-Renewable

Your Short Term Medical certificate is not renewable.

We may cancel coverage if there is fraud or material

misr

epresentation made by or with the knowledge of a

covered person in filing a claim for benefits.

Termination

This policy/certificate will terminate on the earliest of:

• The primary insured’s death. If the policy/certificate

includes dependents, it may be continued after the primary

insured’s death by a spouse, if a covered person;

otherwise, by the youngest child who is a covered person.

• Nonpayment of premiums when due.

• The termination date shown on the Data Page of the policy/

certificate.

• The date we receive a request from you to terminate the

policy/certificate.

• The date there is fraud or material misrepresentation

made by or with the knowledge of a covered person filing

a claim for benefits.

Jun 25 2020 12:01:51 pm

16 of 19

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 and 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.

 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.

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.

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 Insurance Company members call

us at 1-800-657-8205 (TTY 711). For All Savers Insurance Company members, call us at 1-800-291-2634 (TTY 711).

The Financial Information Privacy Notice, 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.

Jun 25 2020 12:01:51 pm

17 of 19



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.

 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

P.O. 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.

 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, please call the toll-free phone number on your health plan

ID card.

 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

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.

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 Insurance Company members call

us at 1-800-657-8205 (TTY 711). For All Savers Insurance Company members, call us at 1-800-291-2634 (TTY 711).

The Financial Information Privacy Notice, 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.

Jun 25 2020 12:01:51 pm

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