Short Term Medical Plus Select A 5000/20/7000 - IN Short Term Health Plan from UnitedHealthcare - Healthpocket

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Short Term Medical Plus Select A 5000/20/7000

$112.41/mo

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Zip Code46227
Applicant12/14/1983 Male
Coverage Start12/15/2018
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Benefits & Coverage

Insurance TypeShort Term Medical Insurance
Insurance ProviderUnitedHealthcare
Plan TypeEPO
Deductible$5,000
Coinsurance20% after deductible
Coverage Max$2,000,000
Application Fee$0

Plan TypeShort Term Medical Insurance
Office Visit for Primary DoctorOffice Visit, History, and Exam only. 20% Coinsurance after deductible
Office Visit for Specialist
Coinsurance20% after deductible
Annual DeductibleIndividual: $5,000.00
Family: $0.00
Separate Prescription Drugs DeductibleNone
Prescription DrugsGeneric: 20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Brand Name: 20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Non-formulary: 20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Annual Out-of-Pocket LimitIndividual: $7,000.00
Family: $21,000.00
Does Out-of-Pocket Limit include deductible?Yes
Lifetime Maximum$2,000,000.00
Out-of-Network CoverageNo

Physicians

Primary Care Physician (PCP) RequiredNo
Specialist Referrals RequiredNo

Preventive Care Coverage

Periodic Health ExamNo
Periodic OB-GYN ExamNo
OB-GYN Exam Conditions20% coinsurance after deductible
Well Baby CareNo

Prescription Drug Coverage

Generic Prescription Drugs20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Brand Prescription Drugs20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Non-Formulary Prescription Drugs Coverage20% coinsurance after deductible Preferred Price Card $3,000 per term max per person You pay for prescriptions at the point of sale, at the lowest price available, and submit a claim to us.
Separate Prescription Drugs DeductibleNone

Hospital Services Coverage

Emergency Room$250 copay, then 20% coinsurance after deductible
Outpatient Lab/X-Ray
Outpatient Surgery20% coinsurance after deductible
Hospitalization

Maternity Coverage

Pre & Postnatal Office VisitNot Covered
Labor & Delivery Hospital StayNot Covered

Additional Coverage

Chiropractic CoverageNot Covered
Mental Health CoverageChosen coinsurance after deductible - limitations apply

Subject to all policy provisions, the following expenses are covered. To be considered for reimbursement, expenses must qualify as covered expenses and are subject to eligible expense limits unless you use a network provider.

Ambulance Services

Ground ambulance services to a hospital for necessary emergency care.

Durable Medical Equipment

Rental of wheelchair, hospital bed, and other durable medical equipment 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.

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 outpatient treatment of spine and back disorders limited to $50 per visit and 6 visits in any 3-month period.

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 Benefit

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 determined by us. The transplant must not be experimental or investigational. Covered expenses for “Listed Transplants” are limited to 2 during a 10-year period, per covered person.

Golden 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.

Please refer to plan brochure for more details.

These are only a general outline of the coverage provisions. It is not an insurance contract, nor part of the insurance certificate. You will find complete coverage details in the policy and certificate.

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 a preexisting condition — A condition: (1) for which medical advice, diagnosis, care, or treatment was 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.
    For a preexisting condition - See brochure for state definition
    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 or 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 dental expenses, including braces and oral surgery, except as provided for in the policy.
  • 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 injuries from participation in professional or semi-professional sports or athletic activities for financial gain, as determined by Golden Rule.
  • For high-dose chemotherapy prior to, in conjunction with, or supported by ABMT/BMT, except as specifically provided under the Transplant Expense Benefits provision.
  • 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.
  • 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.
  • Due to pregnancy (except complications), except as provided in the policy.
  • For diagnostic testing while confined primarily for well-baby care, except as provided in the policy.
  • For treatment of mental disorders, or court-ordered treatment for substance abuse, except as provided in the policy.
  • For preventive care or prophylactic care, including routine physical examinations, premarital examinations, and educational programs, except as provided in the policy.
  • 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.
  • For surrogate parenting
  • For treatments of hyperhidrosis (excessive sweating).
  • For alternative treatments, except as specifically covered by the policy, 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’ compensation 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. Should a workers’ compensation insurance carrier deny coverage for a covered person’s claim, this exclusion will still apply unless the denial is appealed and upheld to the proper government agency.
  • 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 vocational or recreational therapy, vocational rehabilitation, outpatient speech therapy, or occupational therapy, except as provided for in the policy.
  • Resulting from experimental or investigational treatments, or unproven services.

Coordination of Benefits (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 yourcertificate.

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.

Effective Date

Your certificate will take effect on the later 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:

    1. Your application and the appropriate premium payment are actually received by us within 15 days of your signing;**
    2. You are a member of the Federation of American Consumers and Travelers (FACT);
    3. Your application is properly completed and unaltered;
    4. You have answered “no” to question 2 (if other questions are answered “yes,” we will exclude the person(s) listed);
    5. You are a resident of a state in which the certificate form can be issued; and
    6. 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 means 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.

Eligible Expense

An eligible expense means a covered expense as follows:

  • For Network Providers: the contract fee for the provider.
  • For Non-Network Providers: when a covered expense is received as the result of an emergency or as otherwise approved by us, the eligible expense is the lesser of the billed charge or the amount negotiated with the provider. Except as noted above, the eligible expense is the first of the following that can be applied:

    1. The fee negotiated with the provider;
    2. 110% of the fee Medicare allows for the same or similar service in the same area;
    3. The fee set by us after comparing rates from one or more regional or national databases, or schedules for the same or similar service from a geographical area determined by us; or
    4. The fee charged by the provider.

Non-Renewable

Your Short Term MedicalSM certificate is not renewable. You may apply for additional short term coverage (subject to state restrictions), however a condition which was a covered expense under a prior certificate would be considered preexisting under a subsequent certificate. Additional certificates will not be continuations of any previous certificate.

We may cancel coverage if there is fraud or material misrepresentation made by or with the knowledge of a covered person in filing a claim for benefits.

Please refer to plan for for more details.

See brochure for state variations

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Thomason, Eileen
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  • Phone Number
    (317) 887-7771
  • Office Locations
    8711 Us 31 S
    Indianapolis, IN 46227
8711 Us 31 S Indianapolis IN, 46227

Please note that the response to these questions is from Agilehealthinsurance and not the insurer.

Does a short term health insurance plan help cover the costs of prescription drugs?

The coverage varies depending on the plan. Please reference the brochure for more details.

Can I contact someone if I need help choosing the right short term plan?

Absolutely. Our friendly, licensed Product Advisors are ready to assist you.

Call (800) 314-5594

Do you offer the best prices for a short-term health insurance plan?

Whether you buy directly from golden rule, online or on the phone, or through agilehealthinsurance.com, you’ll pay the same premium for the plan. This means that you can enjoy the benefits and convenience of shopping and purchasing your short term health insurance plan right here online and rest assured that you’re getting the best available price for the particular plan.

What if I get a renewable insurance policy at a future date?

Once you receive written confirmation that you are approved for a renewable insurance plan, contact us to cancel the short term plan.

If I cancel my short term plan early is there a penalty or a refund?

After the first month, there is no penalty for cancelling your plan early. You’ll receive a prorated refund for the unused days of coverage. Remember, you must apply for at least one month of coverage, and there are no refunds during the first month.

Do short term health insurance plans include dental and vision benefits?

No. We offer dental insurance and vision insurance which you can purchase separately from a temporary insurance plan. Short term health insurance plans by themselves are designed to protect you in the event of an unexpected illness or injury and are not intended to cover dental and vision care.

If I apply for an insurance plan, am I obligated to buy?

No. You are under no obligation to buy a health insurance plan when using our site. After submitting your application you may cancel it at anytime during the underwriting process.

Golden Rule does charge a nonrefundable $20 application fee for their short-term plans in most states.

If I don’t qualify for short term coverage, will my credit card still get charged?

In most states there is a $20 nonrefundable application fee associated with the Golden Rule short term products.

How will I know if I qualify for short term health insurance coverage?

If applying online, normally you’ll have an answer the next business day. Golden Rule contact you via email.

Answering “yes” to any of the online application’s medical history questions can lengthen the review process. If this applies to you, please submit a paper application.

How soon can my short term health insurance start?

Your policy can take effect on the later of: (1) the requested effective date; or (2) the day after the postmark date affixed by the U.S. Postal Service,* but only if the following conditions are satisfied:

Your application and the appropriate premium payment are actually received by Golden Rule within 15 days of your signing;**

You are a member of the Federation of American Consumers and Travelers (FACT) in most states;

Your application is properly completed and unaltered;

You are a resident of a state in which the certificate form can be issued; and

If the application is submitted by an agent or broker, the agent or broker is properly licensed to submit applications to Golden Rule.

What happens when I reach the end of my coverage period?

At the end of your coverage term, in most states you may apply for another term for short term health insurance coverage.

What if I only need temporary health insurance coverage for less than 30 days?

In most states you can purchase a short term health insurance plan for one month only.

Why would I want short term insurance coverage for a limited amount of time?

You may be a college student and following graduation you’re no longer eligible for your parent’s health plan and you’re looking for your first job. You may be laid off and looking for work. Maybe you’re an early retiree and waiting for Medicare eligibility. A short term plan can help protect you during life-changing events.

What is short term health insurance?

Short term health insurance is temporary coverage designed to fill gaps in coverage. Short term health insurance plans provide you with coverage for a limited period of time, and may be an ideal solution for those between jobs, waiting for other health insurance to start, college grads coming off their parent’s health plan, or retired early and waiting for Medicare eligibility. If you think you’ll need coverage for a longer period of time, you may want to look at renewable individual and family health insurance plans.

The application process for short term health insurance is usually simpler than renewable health insurance. Short term health insurance plans are designed to cover unforeseen accidents or illnesses, rather than to provide comprehensive coverage, and, as such, typically do not include coverage for preventive care, physicals, immunizations, dental or vision care.

Short term health insurance plans typically do not cover preexisting medical conditions. The definition of a preexisting condition varies by state, but, in general, short term health insurance policies exclude coverage for conditions that have been diagnosed or treated within the previous 2 to 5 years. If you have an existing medical condition, you may want to research whether you can extend your current insurance. Employer-sponsored insurance may be extended under a government-regulated option commonly referred to as COBRA (or similar state program), which you should seriously consider if you have an existing medical condition.

PremiumPlan NameDeductible

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.