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 Comparison 3
Optional Benefits 6
Network 7
Medical Benefits 8
State Variations 10
Exclusions & Limitations 14
Plan Provisions 16
Notice of Privacy Practices 17
Who We Are 20
Short Term Medical Plans
In times of transition and change
States:
FL IL IN MI MS
NE PA TN TX WV
DIRECT
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.
Jun 25 2020 12:03:00 pm
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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.
Short Term Medical
Understanding How it Works
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 3-5 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
youre traveling, youre 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 7 for
more details.
* See State Variations for term lengths available in your state.
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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.
(Back to Cover)
Jun 25 2020 12:03:00 pm
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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 7.
DIRECT
Short Term Medical Plans: Value Copay Value Plus
Coverage Term Length
Choose length: See State Variations for term lengths available in your state.
Deductible Type
Per Cause (Deductible and out-of-pocket maximum are applied for each illness or injury.)
>
Option:
Change Deductible Type
from Per Cause to Per Term
Per Term (One deductible for
selected length of coverage)
Option not available.
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:
40% 40% 20%
Coinsurance Out-of-pocket
Maximum
(after deductible,
per person, copays not included)
You pay
up to:
$10,000 $10,000 $5,000
Lifetime Maximum Benefit we will pay (per person):
$250,000 on these plans
1
Doctor Visits
2
Doctor Office Visit, History,
and Exam only
You
pay:
Coinsurance
after deductible
$50 copay
3
Coinsurance
after deductible
Urgent Care Center
$75 copay
Outpatient
2
Emergency Room
You
pay:
$250 copay, then subject to deductible and coinsurance.
Outpatient Surgery, Labs,
X-rays, and PSA Screening
Coinsurance after deductible
Inpatient
2
Hospital Services
You
pay:
Coinsurance after deductible
Pharmacy
2
Prescription (Rx) Drugs
($3,000 max benet)
Not covered Discount Card only
Discount card can help you save an average
of 20-25% on your Rx drugs. Discounts vary
by pharmacy, geographic area, and drug.
Preferred Price Card &
coinsurance after deductible
4
1
These plans are not available in Indiana.
2
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.
3
Number of visits subject to copay varies by coverage term length. Additional visits subject to deductible and coinsurance. See page 8.
4
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.
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Highlights of Network Covered Expenses
(per covered person, per term)
INTERNET
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 7.
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
, $2,500, $5,000, $10,000, or $12,500
>
Option:
Add Supplemental
Accident Benefit
We pay
up to:
$1,000
1
, $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
1
Doctor Visits
3
Doctor Office Visit, History,
and Exam only
You
pay:
Chosen coinsurance
after deductible
Chosen coinsurance
after deductible
$50 copay
4
Coinsurance after
deductible
Urgent Care Center
$75 copay
Outpatient
3
Emergency Room
You
pay:
$250 copay, then subject to deductible and coinsurance.
Outpatient Surgery, Labs,
X-rays, and PSA Screening
Coinsurance after deductible
Inpatient
3
Hospital Services
You
pay:
Coinsurance after deductible
Pharmacy
3
Prescription (Rx) Drugs
($3,000 max benet)
Not covered.
Discount Card only
5
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.
1
These plans are not available in Indiana.
2
$1,000 option not available with the Plus Elite plan.
3
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.
4
Number of visits subject to copay varies by coverage term length. Additional visits subject to deductible and coinsurance. See page 8.
5
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 12:03:00 pm
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Highlights of Network Covered Expenses
(per covered person, per term)
FMO
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 7.
Doctor Visits
3
Doctor Office Visit, History,
and Exam only
You
pay:
Chosen coinsurance
after deductible
Chosen coinsurance
after deductible
$50 copay
4
Coinsurance after
deductible
Urgent Care Center
$75 copay
Outpatient
3
Emergency Room
You
pay:
$250 copay, then subject to deductible and coinsurance.
Outpatient Surgery, Labs,
X-rays, and PSA Screening
Coinsurance after deductible
Inpatient
3
Hospital Services
You
pay:
Coinsurance after deductible
Pharmacy
3
Prescription (Rx) Drugs
($3,000 max benet)
Not covered.
Discount Card only
5
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.
1
$2 million annual maximum in Indiana.
2
$1,000 option not available with the Plus Elite A plan.
3
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.
4
Number of visits subject to copay varies by coverage term length. Additional visits subject to deductible and coinsurance. See page 8.
5
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
1
we will pay (per person):
$2 million on these plans
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
, $2,500, $5,000, $10,000, or $12,500
>
Option:
Add Supplemental
Accident Benefit
We pay
up to:
$1,000
2
, $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
Jun 25 2020 12:03:00 pm
Optional Benefits
Available for additional premium.
>
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Supplemental Accident Optional Benefit for All Plans
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.
Per Term Deductible Option for Short Term Medical Value and Plus Plans Only
Change your deductible type from Per Cause to Per Term. Instead of a deductible for each illness
or injury, a Per Term deductible offers you one amount to meet during your plan’s coverage term.
Per Term means fewer out-of-pocket medical costs.
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These plans provide access to a network of doctors, hospitals, and other providers that
offer you quality health care.
1
Visit UHOne.com and select Find A Doctor to search
for UnitedHealthcare
Choice network providers.
Nationwide Network
Use any doctor in the Choice
network across the nation.
No Primary Care Physician
(P
CP) required. Note: There
are no non-network benefits.
1
1
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.
2
UnitedHealth Group Annual Form 10-K for year ended 12/31/19.
AL
WA
VT
UT
OR
ND
NY
NH
MT
MN
ME
ID
CA
NV
WY
AZ
NM
CO
SD
NE
KS
OK
TX
LA
AR
MO
IA
WI
MI
IL
IN
OH
KY
TN
MS
GA
FL
SC
NC
VA
PA
WV
AK
Access to Quality Care from:
Any network specialist without
needing a referral.
1.4 million physicians and other
health care professionals.
2
More than 6,500 hospitals and
other facilities.
2
No Balance Billing
The 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.
ALABAMA
ARKANSAS
NORTH CAROLINA
OHIO
OKLAHOMA
Choice Network States
Short Term Medical
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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.
N
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
he
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 Value, 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.
A
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 12:03:00 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
Childrens 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
d
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.
G
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 12:03:00 pm
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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.
State Variations
Short Term Medical
Please see below for state availability and applicable state-specific benefits, exclusions, and limitations.
Jun 25 2020 12:03:00 pm
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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.
State Variations, continued
Short Term Medical
Please see below for state availability and applicable state-specific benefits, exclusions, and limitations.
Jun 25 2020 12:03:00 pm
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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
O
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 12:03:00 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 12:03:00 pm
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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
s
pecifically provided for by the policy.
For a preexisting condition — A condition:
(1) for which medical advice, diagnosis, care, or treatment
w
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.
Whats not covered (all plans)
Jun 25 2020 12:03:00 pm
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Whats 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’
c
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 12:03:00 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
la
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
me
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 UHOne.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 12:03:00 pm
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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 12:03:00 pm
18 of 20
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 WorkersCompensation including disclosures required by state workerscompensation 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.
Jun 25 2020 12:03:00 pm
19 of 20
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.
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 12:03:00 pm
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* As of 12/18/19. For the latest rating, access www.ambest.com.
© 2020 United HealthCare Services, Inc.
45061E-G-0820
Who we are.
Golden Rule Insurance Company, a UnitedHealthcare
company, is the underwriter of plans featured in this
brochure. We have been serving the specific needs of
individuals and families buying their own coverage for over
70 years. Plans are administered by United Healthcare
Services, Inc.
Golden Rule Insurance Company is rated “A” (Excellent)
by A.M. Best.* This worldwide independent organization
examines insurance companies and other businesses,
and publishes its opinion about them. This rating is an
i
ndication of our financial strength and stability.
Our plans offer easy-to-understand health insurance
designed for individuals and families in times of
transition and change. Plans only available to members
of FACT, the Federation of American Consumers and
Travelers (see below). If you’re not already a member,
you can enroll with your Short Term Medical application
to be eligible to apply for these plans.
What is FACT?
FACT is an independent consumer association whose
members benefit from the “pooling” of resources. Benefits
range from medical savings to consumer service discounts.
FACT’s principal office is in Jonesboro, Arkansas. FACT and
Golden Rule Insurance Company are separate organizations.
Neither is responsible for the performance of the other.
FACT has contracted with Golden Rule Insurance Company
to provide its members with access to these health
insurance plans. FACT does not receive any compensation
from Golden Rule Insurance Company.
Is there a cost for joining FACT?
Yes, there are membership dues and they can be paid with
your regular health insurance premium, as opposed to
making a separate payment.
What are the basic FACT membership benefits?
FACT makes it easy for members to choose from a full
menu of important benefits, including:
As a member of FACT, your information is kept private and
is not shared with any third parties. Please visit the FACT
website, www.usafact.org/privacy_policy.html, for a complete
FACT Privacy Statement. FACT may change or discontinue
any of its membership benefits at any time. For the most
current information, including full detailed lists of member
benefits, visit FACT’s website at www.usafact.org or call
toll-free at (800) USA-FACT.
Accidental Death Benefits
Consumer Information & Hotline
Retail & Service Discounts
Travel Discounts
Pet Coverage
Scholarships
Your Short Term Medical certificate is not renewable.
Short Term Medical is issued for a specific period of time.
In most cases, coverage will be determined by the master
polic
y issued in Arkansas and subject to Arkansas law.
We will notify you in advance of any changes in coverage
or benefits. Nonrefundable $20 application fee required.
Jun 25 2020 12:03:00 pm