A Guide to Buying Health Insurance

We agree — buying health insurance can be difficult. There are many companies offering several plans. Benefits are different. Fine print is hard to read. Terms are unfamiliar. And the cost can be surprising.

On this page, we offer six clear steps to help you through the process of selecting a health plan that fits your budget and a company that meets your needs as well.

1) Determine what you are looking for in a health insurance plan.

• Copay for doctor visits for young children?
• Lower premiums — most concerned with serious illness?

• Are tax-advantages important?
  2) Review plans from reputable companies.
  
  • Check an independent rating agency like A.M. Best or Standard and Poor’s.
    3) Know what you are responsible to pay.
    
    • Copay: fixed amount an insured must pay at the time of service (i.e., doctor visit or
      prescription).
      
    • Deductible: a flat amount that an insured is required to pay before the insurance will pay any
      benefits.
      
    • Coinsurance: the percentage (for example, 80%) paid by the insurance company and percentage
      (20%) paid by the insured of all covered medical expenses once the deductible is met.
      

4) Understand what’s covered and what’s not covered by the insurance plan.

• • All plans have exclusions and limitations and you need to know what they are (see pages 13-15).
    5) Research the network.
    
  • • Network: health-care providers (physicians, hospitals, and other facilities) that are contracted by
    the insurance company to provide care at a discounted price.
    
• Are the doctors and hospitals you want to use part of the network offered by the company?
  6) Figure out the bottom line — your total annual cost in a good health year and a bad health year.
  

Which Plan Best Fits Your Needs?

Whether you are seeking lower-cost health insurance, experienced a recent change in employment or family status, or are self-employed, we offer you and your family a variety of coverage options at competitive prices in many states.

Both the amount of benefits and the premium will vary based upon the plan you select.

*Out-of-pocket exposure is deductible, coinsurance, and copays. Under all plans, additional expenses may be incurred that are not eligible for reimbursement by the insurance.

Quality Care at Significant Savings — The Network Advantage

Access to the right doctors can be the most important part of your health care.

High Deductible Health Plans

With high deductible plans, you’re keeping more of your money and taking responsibility for covering minor or routine health-care expenses — if they come up. The higher the deductible, the lower your premiums. Saver 80^SM is our lowest premium plan. This plan provides coverage for hospital confinements, surgical procedures in or out of the hospital, and the more costly outpatient expenses, such as CAT scans and MRIs.

Simple to Use

Golden Rule’s top-selling high deductible plan — Plan 100^® — pays 100% of covered expenses once you meet your calendar-year deductible. Your benefits are not complicated with multiple copays or coinsurance.

Comprehensive Coverage

• You choose $3 million or $5 million lifetime maximum benefit per covered person.
• Plan 100^® and Plan 80^SM include preventive care and child immunizations with no waiting period (first-dollar
  coverage available).
  
• Add optional benefits to increase coverage (see Optional Benefits on page 10 for details).

Preferred price card — Receive the lowest price available from your chosen pharmacy at the time of purchase on prescription drugs. You pay for the prescription at the point of sale and submit a claim to Golden Rule for reimbursement based on your medical plan.

Discount card — If you choose a plan without an outpatient drug benefit, this card allows you to obtain prescription drugs at an average savings of 20% to 25%.*

This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information on pages 11-15.

*Discounts vary by pharmacy, geographic area, and drug.

Convenient Doctor Office Copay Benefits

Copay plans are more like traditional employer plans with a copayment for routine health-care expenses. When you use a Preferred network doctor for an office visit, we pay 100% of history and exam fees after a $35 copay with Copay Select^SM. Office visit expenses outside your network are not eligible for copay benefits.

Adult and Child Preventive Care Included

You pay $35 for the doctor office visit with Copay Select^SM. X-rays and lab tests are covered at 80% — you pay 20%.

Prescription Drug* Card Benefits (Copay Select^SM Only)

• Tier 1 drugs — $15 copay.
  • Tiers 2-4 drugs — combined $150 per person, per calendar-year deductible, then:
    • $30 copay for Tier 2 drugs.
    • $60 copay for Tier 3 drugs.
    • 25% coinsurance (you pay) for Tier 4 drugs.

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

(Copay Select^SM Only)

• You choose $3 million or $5 million lifetime maximum benefit per covered person.
• Covered inpatient and outpatient expenses are reimbursed at 80% once the deductible has been met.

Copay Saver^SM

The Copay Saver^SM plan provides the convenience of copays for doctor office visits (limited to 2 visits per person, per calendar year) for a lower monthly premium.

*We have a preferred drug list, which changes periodically. Feb 9 2010 02:38:05

6

This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information on pages 11-15.

*NOTE: Tier status for a prescription drug may be determined by accessing your prescription drug benefits via our Web site or by calling the telephone number on your identification card. The tier to which a prescription drug is assigned may change as detailed in your policy. If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price. Feb 9 2010 02:38:05

HSA Plans Offer Quality Coverage, Savings

HSA Plans simply combine a lower-cost, high deductible health insurance plan and a tax-favored savings account.

Lower Premiums, Tax-Advantaged Savings, and an Attractive Interest Rate*

High deductible plans typically cost a lot less than many copay or traditional plans. This means lower premiums for you. You can then take the premium savings and place it into your health savings account.

• You get a tax deduction on the money you put in your HSA.
• Your dollars can grow tax-deferred.
• You spend the savings tax-free to help pay your deductible or for qualified medical care (including prescriptions, vision, or dental care).
• What you don’t use in your account will continue to accumulate year after year. Then, if you ever need it for health-care expenses, the money will be there.
• With Golden Rule’s HSA custodian, you’ll also earn interest on your savings, beginning with the first dollar
  deposited.
  

Traditional Insurance High Deductible Insurance Premium Savings $ Premium $ Premium $ Put Into HSA

Bottom line — HSAs can help make health insurance more affordable.

*See HSA insert for important information.

Preferred price card — Receive the lowest price available from your chosen pharmacy at the time of purchase on prescription drugs. You pay for the prescription at the point of sale and submit a claim to Golden Rule for reimbursement based on your medical plan.

Discount card — If you choose a plan without an outpatient drug benefit, this card allows you to obtain prescription drugs at an average savings of 20% to 25%.*

This chart only summarizes standard covered expenses, exclusions, and limitations of each plan. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits unless you use a network. We recommend review of the more detailed plan information on pages 11-15.

*Discounts vary by pharmacy, geographic area, and drug.

About Your HSA

We have chosen OptumHealth Bank, a leading administrator of health savings accounts (HSA), as our financial institution. Your HSA funds are deposited at OptumHealth Bank in a custodial account. OptumHealth Bank, Member FDIC, will service your account and send information directly to you about your HSA.

You will receive your new Health Savings Account Card^SM and PIN in separate mailings. Once you activate your card, you can use it at:

• Any point-of-service location (such as a

doctor’s office or pharmacy) that accepts

MasterCard® debit cards.

• Any ATM displaying the MasterCard® brand

mark. ($1.50 per transaction OptumHealth

Bank fee. In addition, the bank/ATM you use to

withdraw funds may charge you its own fee

(variable by bank) for the transaction.)

You can also access your HSA funds through:

• Online bill payment at OptumHealthBank.com
• Checks, if you choose to purchase them.

HSA deposits are set up on the same payment plan as premiums for Golden Rule health insurance coverage.

Lump-sum deposits are also accepted by

OptumHealth Bank; however, you must continue to deposit the $25 monthly minimum with your premium payment. OptumHealth Bank will provide online monthly statements detailing your account balance and activity. If you prefer to have statements mailed to your home, simply notify OptumHealth Bank. You can opt out of electronic statements at its Web site (OptumHealthBank.com), call customer service to do so, or send your request to P.O. Box

271629, Salt Lake City, UT 84127-1629.

Account Information by Phone or Online

Who is responsible for my HSA?

As custodian, OptumHealth Bank is responsible for your HSA funds. OptumHealth Bank’s deposits are insured by the Federal Deposit Insurance Corporation (FDIC).

Please be aware that the money market and mutual

fund investment options are NOT guaranteed by OptumHealth Bank, are NOT FDIC-insured, and may

lose value. We encourage you to read the prospectus of each fund carefully before investing and seek the advice of an investment professional you trust.

Individuals aged 55+ may contribute an additional
$1,000 for tax year 2009 and after

You will receive a Health Savings Account card from OptumHealth Bank shortly after your qualified medical coverage becomes effective. HSA withdrawals can be made by simply using your

Health Savings Account card at any point-of-service

location (such as a doctor’s office or pharmacy) that accepts MasterCard® debit cards.

If you prefer, you can purchase the qualified health insurance coverage from Golden Rule and set up your savings account with another qualified custodian.

37379-G-0609 Copyright © 2009 Golden Rule Insurance Company, the underwriter of these plans marketed under the UnitedHealthOne brand. In LA, plans are offered by United HealthCare Insurance Company and administered by Golden Rule.

$5 Million Lifetime Maximum Benefit

Upgrade your coverage to $5,000,000 of covered expenses per person.

Enhanced Preventive Care Benefits Package

This option is available with any Preferred network plan except Copay Select^SM.

• $35 copay on each preventive care office visit (primary care, OBGYN, etc).
• The following charges for preventive care that are performed in conjunction with the office visit are exempt from the deductible and coinsurance whether performed in the doctor’s office or elsewhere:

—

Child (under age 19) and adult immunizations.

—

Urinalysis and blood tests.

—

Bone density screens.

—

EKG and cardiac stress tests.

—

Pap, cervical smears and digital rectal exams.

—

FDA-approved screenings for HPV.

Prescription Drug Card Benefit

This option is only available with Plan 100^® and Plan 80^SM. With this benefit, you pay:

• Tier 1 drugs — $15 copay.
  • Tiers 2-4 drugs — combined $150 per person, per calendar-year deductible, then:
    • Tier 2 drugs — $30 copay.
    • Tier 3 drugs — $60 copay.

— Tier 4 drugs — you pay 25% coinsurance. (Maximum $3,000 per covered person, per calendar year.)

If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price.

Prescription Drug Benefit Buy-Up

This option is only available with Copay Select^SM. Eliminates the $3,000 calendar-year limit.

Two Additional Doctor Office Visits

This option is only available with Copay Saver^SM.
Increase the number of Copay Doctor Office Visits from 2 to 4 per
person, per calendar year.

First-Dollar Accident Benefit

This benefit provides up-front coverage for unexpected injuries and is limited to your choice of $500 or $1,000 of first-dollar coverage for treatment of an injury within 90 days of an accident. Plan deductible must be greater than or equal to the maximum benefit amount.

HSA Hospital Indemnity Rider

This option is only available with HSA 100^® and HSA Saver^SM. HSA Hospital Indemnity Rider is designed to help protect against major hospitalization expenses during early months of coverage when cash hasn’t yet accumulated in your savings account. (See HSA insert for details.)

Maternity Benefit

This option is only available with Plan 100^®, Plan 80^SM, Saver 80^SM,

Copay Select^SM, and Copay Saver^SM.
This optional benefit helps cover the costs for routine pregnancy and
delivery. You pay 20%; we pay 80% of covered expenses. After 4
benefit years, the maximum covered expense amount is $7,500.

No covered expenses will be considered for reimbursement for a
pregnancy beginning before the maternity benefit’s effective date.

You’ve made the decision to help protect your family’s health by seeking insurance; shouldn’t you consider helping protect their financial future too?

Term life insurance may be an ideal benefit to make sure you provide for your loved ones’ future.

Consider your current financial picture and ask, “Without a term life insurance benefit paid to my loved ones upon my death, would they be able to:

• Pay for funeral expenses?
• Pay the mortgage or other debts?
• Save for college or retire comfortably?”

Remember to select this option as you apply for health coverage.

Enhanced Term Life Benefit

You may choose an optional term life insurance benefit for you and/or a spouse who is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The term life benefit expires when a covered person reaches age 65.

You select one of three benefit amounts. You may select different amounts for you and your spouse.

Benefit Amounts: $50,000 $100,000 $150,000

Accidental Death Benefit

This benefit provides $50,000 in coverage in the event of an accidental death for you and/or your spouse if your spouse is also a covered person under the health plan. You and/or your spouse must be age 18 or older. The accidental death benefit expires when a covered person reaches age 65. It may be purchased with or without the term life benefit.

Motorcyclists are not eligible for this benefit.

Keeping your smile beautiful doesn’t have to be expensive. You can now upgrade your health plan with an optional dental benefit that can help keep you smiling brightly. UnitedHealthcare’s extensive network of dental care providers can offer you significant savings.

UnitedHealthcare Dental Benefit Rider — Two Options to Choose From

With Dental Coverage From UnitedHealthcare — You Have the Advantage.

With a United Healthcare dental rider, your family has

access to over 73,000 network dentists. The result can

be significant discounts on quality care, and you

never file a claim form. A healthy smile can be easier

than you thought.

Preventive services have no waiting period and include routine dental exams, routine X-rays, cleaning, fluoride treatment, sealants, and space maintainers.

Basic services have a 6-month waiting period and include dental exams, X-rays, routine extractions, treatment to ease dental pain, and simple fillings.

Major services have a 12-month waiting period and

include treatment for diseases of the pulp (including root canals), bone and other tissues supporting the teeth, crowns, inlays, onlays, veneers, bridges, dentures, and oral surgery for impactions.

Keep an eye on your family’s vision health by adding our optional Vision Benefit rider to your health plan today. Our extensive vision care network includes – 24,000 private practice and retail chain providers.* We’ll help keep your family seeing clearly, so you can focus on savings!

UnitedHealthcare Vision Benefit Rider

You may use a non-network provider, but by staying in-network you are eligible to receive better discounts:

• Eye exam — $10 copay – once every 12 months.
• Frames — $25 copay – once every 24 months.
• Lenses — $25 copay – once every 12 months
• Contacts in lieu of glasses — $25 copay – once every 12 months.

*Network availability may vary by state, and a specific vision care provider’s contract status can change at any time. Therefore, before
you receive care, it is recommended that you verify with the vision care provider that he or she is still contracted with the network.

Policy Form SA-S-1356R

38526-G-1009 Copyright © 2009 Golden Rule Insurance Company. UnitedHealthOne is a brand name used for products
underwritten by Golden Rule Insurance Company. This product is administered by Spectera, Inc. Additional premium is required.
Availability varies by state. Please see the corresponding health product brochure and important information on the back of this page.

Medical Expense Benefits

• Daily hospital* room and board and nursing services at the most
  common semiprivate rate.
  
• Charges for intensive care unit.
  
• Hospital emergency room treatment of an injury or illness (subject to an additional $100 copay each time the emergency room is used for an illness not resulting in confinement — does not apply to HSA Plans).
• Services and supplies, including drugs and medicines, which are routinely provided by the hospital to persons for use while they are inpatients.
• Professional fees of doctors and surgeons (but not for standby
  availability).
  
• Dressings, sutures, casts, or other necessary medical supplies.
• Professional fees for outpatient services of licensed physical therapists.
• Diagnostic testing using radiologic, ultrasonographic, or laboratory
  services in or out of the hospital.
  
• Local ground ambulance service to the nearest hospital for necessary emergency care. Air ambulance, within U.S., if requested by police or medical authorities at the site of emergency.
• Charges for operating, treatment, or recovery room for surgery.
• Dental expenses due to an injury which damages natural teeth if
  expenses are incurred within six months.
  
• Surgical treatment of TMJ disorders (see limitations on page 14).
• Cost and administration of anesthetic, oxygen, and other gases.
• Radiation therapy or chemotherapy.
• Prescription drugs.
• Hemodialysis, processing, and administration of blood and components.
• Pap smear.
• Artificial eyes, larynx, breast prosthesis, or basic artificial limbs (but not replacements).
• Limited routine newborn care.
• Expenses for mammography exams, prostate screening, and child
  health services (for less than age 13 years) are not subject to the
  deductible.
  
• Surgery in a doctor’s office or at an outpatient surgical facility,
  including services and supplies.
  

• Occupational therapy following a covered treatment for traumatic hand injuries.
• Rehabilitation and extended care facility services that begin within 14 days of a 3-day or more hospital stay, for the same illness or injury. Combined calendar year maximum of 60 days for both rehabilitation and extended care facilities expenses.

Preventive Care Expense Benefits

No waiting period for wellness benefits. See pages 5, 7, and 9 for coverage

details.
(Except where noted, Plan 80, Plan 100, and HSA 100 subject to the
applicable deductible amount and coinsurance percentage. Copay Select
exempt from any applicable deductible amount.)

Covered expenses are expanded to include charges for the following when
incurred for preventive care:

• Routine office visits (including well-baby).
• Childhood immunizations for each eligible child ages 13-18.
• Childhood immunizations for each eligible child ages 0-12 are not
  subject to the deductible.
  
• Adult immunizations.
• Urinalysis and blood tests.
• Bone density screenings.
• Electrocardiagrams. (EKG’s).
• Cardiac stress tests.
• Mammography screenings are not subject to the deductible.
• Cervical smears and pap smears.
• Prostate-specific antigen tests and digital rectal examinations are not subject to the deductible.
• FDA-approved screenings for the detection of the human

papillomavirus (HPV) and vaccinations for HPV. Preventive Care Expense Benefits will not include and no benefits will be paid for computerized axial tomography (CAT or CT scan), magnetic resonance imaging (MRI) or positron emission tomography (PET scan) performed on a routine or preventive basis.

For information on additional Plan provisions, including Transplant Expense Benefit, Limited Exclusion for AIDS or HIV-related Disease, Notification Requirements, Preexisting Conditions, General Exclusions, General Limitations, and Other Plan Provisions, read pages 13-15.

*Hospital does not include a nursing home or convalescent home or an extended care facility.

Inpatient Expense Benefits

• Daily hospital* room and board and nursing services at the most common semiprivate rate.
• Charges for intensive care unit.
• Drugs, medicines, dressings, sutures, casts, or other necessary medical supplies.
• Artificial limbs, eyes, larynx, or breast prosthesis (but not
  replacements).
  
• Professional fees of doctors and surgeons (but not for standby availability).
• Hemodialysis, processing, and administration of blood or
  components.
  
• Charges for an operating, treatment, or recovery room for surgery.
• Cost and administration of an anesthetic, oxygen, or other gases.
• Radiation therapy or chemotherapy and diagnostic tests using radiologic, ultrasonographic, or laboratory services.
• Local ground ambulance service to the nearest hospital for
  necessary emergency care. Air ambulance, within U.S., if
  requested by police or medical authorities at the site of the
  emergency.
  

Outpatient Expense Benefits

• Charges for outpatient surgery, including the fee made by an outpatient surgical facility, the primary surgeon, the assistant surgeon, and/or administration of anesthetic.
• Hemodialysis, radiation, and chemotherapy.
• Prescription drugs to protect against organ rejection in transplant cases.
  
• Mammography, Pap smear, and PSA test fees.
• Hospital emergency room treatment of an injury or illness (subject to limitations shown on pages 5, 7, and 9).
• CAT scan and MRI testing.
• Diagnostic testing related to, and performed within, 14 days prior to surgery or inpatient confinement.

• Copay Saver^SM plan includes two doctor office copay visits per year (see page 7).
• Copay Saver^SM plan includes coverage for generic prescription drugs (see page 7).

Health-Care Provider Networks

Choosing a Preferred network offers you a significant premium discount, and in most cases, an extensive network of doctors and hospitals.* Otherwise, Golden Rule health insurance plans include access to one of our savings-based networks.

Transplant Expense Benefit

Preexisting Conditions

Preexisting conditions will not be covered during the first 12 months after an individual becomes a covered person. This exclusion will not apply to conditions that are both: (a) fully disclosed to Golden Rule in the individual’s application; and (b) not excluded or limited by our underwriters.

A preexisting condition is an injury or illness: (a) for which medical advice, diagnosis, care, or treatment was recommended to or received by a covered person within 12 months prior to the applicable effective date for coverage of the illness or injury; or (b) a pregnancy existing on the applicable effective date the covered person becomes insured under the policy.

General Exclusions

No benefits are payable for expenses which:

• Are due to pregnancy (except for complications of pregnancy), unless optional coverage is selected, if available.
• Are for routine or preventive care unless provided for in the policy.
• Are incurred while confined primarily for custodial, rehabilitative, or educational care or nursing services.
• Result from or in the course of employment for wage or profit, if the covered person is insured, or is required to be insured, by workers’ compensation insurance pursuant to applicable state or federal law. If you enter into a settlement that waives a covered person’s right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply.
• Are in relation to, or incurred in conjunction with, investigational treatment.
• Are for dental expenses or oral surgery, eyeglasses, contacts, eye refraction, hearing aids, or any examination or fitting related to these.
• Are for modification of the physical body, including breast
  reduction or augmentation.
  
• Are incurred for cosmetic or aesthetic reasons, such as weight modification or surgical treatment of obesity.
• Would not have been charged in the absence of insurance.
• Are for eye surgery to correct nearsightedness, farsightedness, or astigmatism.

*Using UnitedHealthcare Choice Plus network, available in most areas.

• Result from war, intentionally self-inflicted bodily harm (unless insane), or participation in a felony (whether or not charged).
• Are for treatment of temporomandibular joint disorders, except as may be provided for under covered expenses.
• Are incurred for animal-to-human organ transplants, artificial or mechanical organs, procurement or transportation of the organ or tissue, or the cost of keeping a donor alive.
• Are incurred for marriage, family, or child counseling.
• Are for recreational or vocational therapy or rehabilitation.
• Are incurred for services performed by an immediate family
  member.
  
• Are not specifically provided for in the policy or incurred while your policy is not in force.
• Are for any drug, treatment, or procedure that promotes
  conception or prevents childbirth.
  
• Are for any drug or treatment that prevents conception.
• Are for treatment of intractable pain as defined in the policy.
• Result from intoxication, as defined by applicable state law in the state where the illness occurred, or under the influence of illegal narcotics or controlled substances unless administered or prescribed by a doctor.
• Are for or related to surrogate parenting.
• Are for or related to treatment of hyperhidrosis (excessive
  sweating).
  
• Are for fetal reduction surgery.
• Are for alternative treatments, except as specifically identified as covered expenses under the policy, including: acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, rolfing, and other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health.

Benefits will not be paid for services or supplies that are not medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy.

General Limitations

• Expenses incurred by a covered person for treatment of tonsils, adenoids, middle ear disorders, hemorrhoids, hernia, or any disorders of the reproductive organs are not covered during the covered person’s first six months of coverage under the policy. This provision will not apply if treatment is provided on an “emergency” basis. “Emergency” means a medical condition manifesting itself by acute signs or symptoms that could reasonably result in placing a person’s life or limb in danger if medical attention is not provided within 24 hours.

• Covered expenses will not include more than what was
  determined to be the reasonable and customary charge for a
  service or supply.
  
• Transplants eligible for coverage under the Transplant Expense Benefit are limited to two transplants in a 10-year period.
• Charges for an assistant surgeon are limited to 20% of the
  primary surgeon’s covered fee.
  
• Covered expenses for surgical treatment of TMJ, excluding tooth extractions, are limited to $10,000 per covered person.
• All diagnoses or treatments of mental disorders, as defined in the policy, including substance abuse, are limited to a lifetime maximum benefit of $3,000 (not covered in Saver Plans). Covered expenses for outpatient diagnosis or treatment of mental disorders are further limited to $50 per visit. As with any other illness or injury, inpatient care that is primarily for educational or rehabilitative care is not covered.
• Covered outpatient expenses relating to diagnosis or treatment of any spine or back disorders are limited to a maximum of $2,000 per calendar year. CAT scan and MRI tests are not subject to this limitation.
• Covered expenses are limited to no more than a 34-day supply for any one outpatient prescription drug order or refill.

Effective Date

For injuries, the effective date for a mailed application will be the later of: (a) the requested effective date, if any, shown on the application; or

(b) the date upon which the original application is actually received by

Golden Rule. For an application sent by any electronic method, including fax, the effective date for injuries will be the later of: (a) the requested effective date, if any, shown on the application; or (b) the day after the date upon which the application is actually received by Golden Rule.

The effective date for illnesses will be the same as for injuries if you are replacing prior coverage within 62 days of application for this coverage and disclose replacement information on the initial application for insurance. If replacement information is not disclosed on the initial application for insurance, the effective date for illnesses will be the 15th day after the effective date for injuries. Illnesses that begin prior to that 15th day will be treated as preexisting conditions and will not be covered until the individual has been a covered person for 12 months.

Premium

We may adjust the premium rates from time to time. Premium rates are set by class, and you will not be singled out for a premium change regardless of your health. The policy plan, age and sex of covered persons, type and level of benefits, time the policy has been in force, and your place of residence are factors that may be used in setting rate classes. Premiums will increase the longer you are insured.

Home Health Care

To qualify for benefits, home health care must be provided through a

licensed home health-care agency. Covered expenses for home health aide services are limited to seven visits per week and 60 visits per calendar year. Outpatient private duty registered nurse services are limited to a lifetime maximum of 1,000 hours. Intermittent RN services (up to 4 hours each) limited to $75 per visit, and deemed to be 2 hours applied to the lifetime maximum.

Hospice Care

To qualify for benefits, a Hospice Care program for a terminally ill covered person must be licensed by the state in which it operates. Benefits for inpatient care in a hospice are limited to 180 days in a covered person’s lifetime. Covered expenses for room and board are limited to the most common semiprivate room rate of the hospital or nursing home with which the hospice is associated.

Dependents

For purposes of this coverage, eligible dependents are your lawful spouse and eligible children. Eligible children must be unmarried and under 25 years of age or medically certified as disabled and dependent on you at time of application.

Termination of a Covered Person

A covered person’s coverage will terminate on the date that person no longer meets the eligibility requirements or if the covered person commits fraud or intentional misrepresentation.

Continued Eligibility Requirements

A covered person’s eligibility will cease on the earlier of the date a covered person:

• Ceases to be a dependent; or
• Accepts an employer’s contribution to the premium payment or treats the policy as part of an employer-provided health plan.

Renewability

You may renew coverage by paying the premium as it comes due. We may decline renewal only:

• For failure to pay premium; or
• If we decline to renew all policies just like yours issued to
  everyone in the state where you are then living.
  

Underwriting

Coverage will not be issued as a supplement to other health plans that you may have at the time of application. Plans are subject to health underwriting.

Conditions Prior to Legal Action

To help resolve disputes before litigation, the policy requires that you provide us with written notice of intent to sue as a condition prior to legal action. This notice must identify the source of the disagreement, including all relevant facts and information supporting your position. Unless prohibited by law, any action for extra-contractual or punitive damages is waived if the contract claims at issue are paid or the disagreement is resolved or corrected within 30 days of the written notice.

CoverColorado Plan Notice Form

You and/or your dependents may qualify for health insurance from CoverColorado as Eligible Individuals, as defined under the federal “Health Insurance Portability and Accountability Act of 1996.”

Generally, you are eligible if you:

• Have had 18 months of continuous prior health insurance coverage;
• Were most recently covered under a group health plan;*
• Have elected and exhausted COBRA or state continuation of benefits coverage;
• Are not eligible for any other group health coverage, Medicare, or Medicaid; and
• Do not have other health insurance.

* Group health plan = coverage existing in connection with employment.

You also may be eligible for participation in the plan, without first requiring application to a carrier for health coverage, if a licensed physician has diagnosed you with a medical condition that is on the list of presumptive medical conditions established by the CoverColorado Board of Directors.

Other eligibility requirements, exclusions, and limitations may apply.

You may apply to CoverColorado for a determination of your eligibility for insurance on application forms available from CoverColorado. A premium will be charged for this insurance if your application is accepted.

For more information regarding CoverColorado, including benefits and exclusions, please contact:

Plan Representative CoverColorado 425 South Cherry Street, Suite 160 Glendale, CO 80246

(303) 863-1960

(800) 259-2656 (TDD)

Colorado law requires carriers to make available a Colorado Health Benefit Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within (3) business days to a potential policyholder who has expressed interest in a particular plan or who has selected the plan as a finalist from which the ultimate selection will be made. The carrier also must provide the form, upon oral or written request, within three (3) business days, to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier.

NOTICE OF INFORMATION PRACTICES

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

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.

The terms “information” or “health information” in this notice include any personal information that is created or received by a health care provider or health plan that relates to your physical or mental health or condition, the provision of health care to you, orthe payment for such health care.

We have the right to change our privacy practices. If we do, we will provide the revised notice to you within 60 days by direct mail or post it on our Web sites listed at the bottom of this page.

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);
• To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected; and
  • Where required by law.
    We have the right to use and disclose health information to pay
    
  • for your health care and operate our business. For example, we
    may use your health information:
    
• For Payment of premiums due us and to process claims for health care services you receive.
• For Treatment. We may disclose health 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 and to help manage 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 restriction on its use and disclosure of the information.
• For Appointment Reminders. We may use 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:

• 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 permitted by law.
• For Public Health Activities such as reporting disease outbreaks.
• For Reporting Victims of Abuse, Neglect, or Domestic Violence to government authorities, including a social serviceor protective service agency.
• For Health Oversight Activities such as 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.
• To Avoid a Serious Threat to Health or Safety by, for example, disclosing information to public health agencies.

• For Specialized Government Functions such as military and veteran activities, national security and intelligence activities,and the protective services for the President and others.
• For Workers Compensation including disclosures required by state workers compensation laws of job-related injuries.
• For Research Purposes such as research related to the prevention of disease or disability, if the research study meets all 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 asauthorized by law. We may also disclose information to funeraldirectors as necessary to carry out their duties.
• For Organ Procurement Purposes. We may use or disclose information for procurement, banking, or transplantation of organs, eyes, or tissue.

If none of the above reasons apply, then we must get your written authorization to use or disclose your health information. If a use or disclosure of health information is prohibited or materially limited by other applicable law, it is our intent to meet the requirements of the more stringent law. In some states, your authorization may also be required for disclosure of your health information. In many states, your authorization may be required in order for us to disclose your highly confidential health information. 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, contact the phone number listed on your 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 its 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).
• You have the right to see and obtain a copy of health information that may be used to make decisions about you such as claims and case or medical management records. You also may receive a summary of this health information. You must make a written request to inspect and copy your health information. In certain limited circumstances, we may deny your request to inspect and copy your health information.
• You have the right to ask to amend information we maintain about you if you believe the health information about you is wrong or incomplete. We will notify you within 30 days if we deny your request and provide a reason for our decision.If we deny your request, you may have a statement of your disagreement added to your health information. We will notify you in writing of any amendments we make at your request.We will provide updates to all parties that have received information from us within the past two years (seven years for support organizations).
• You have the right to receive an accounting of disclosures of your information made by us during the six years prior to you’re request. This accounting will not include disclosures of information: (i) made prior to April 14, 2003; (ii) for treatment,payment, and health care operations purposes; (iii) to you or pursuant to your authorization; and (iv) to correctional institutions or law enforcement officials; and (v) other disclosures that 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 upon request. In addition, you may obtain a copy of this notice at our Web sites, www.eAMS.com or www.goldenrule.com.