UnitedHealthcare Illinois Health Insurance Plans
More than 26 million customers entrust UnitedHealthcare with their health insurance needs.* The network plans can ease access to high-quality care from physicians and hospitals nationwide. Together, we combine our strength and stability with nearly three decades of experience serving customers of all sizes.
In Illinois the United Health Care network is as big as strong as anywhere and the individual health insurance market is well served by United Health Care’s many great plan designs and pricing.
Illinois Health Insurance Plans
Copay Select- the most traditional plan from United Health One includes office visits and prescription coverage from the first day of the policy with a copay.
Copay Saver- avoid this plan period. It is the most absurd idea for a health insurance plan I have ever seen. If an agent tries to sneak sell it to you, get rid of him or her.
Saver 80- indemnity plan that only covers hospitalization. Might leave you high and dry if you need to see many doctors, for this reason the plan 80 which is next is 100% the better choice even though it costs a few dollars more.
Plan 80 – no office visits or prescription copays but the plan covers everything after the deductible and coinsurance at 100%. Remember 100% after the coinsurance and deductible. It is called Plan 80 because it has coinsurance.
Plan 100 – same as Plan 80 with no coinsurance.
HSA 100- Same as Plan 100 with a Health Savings Account attached.
HSA 80 – same Plan 80 with a Health Savings Account attached.
UnitedHealthOne
UnitedHealthOne is the brand name of the UnitedHealthcare family of companies that offers personal health insurance products. Golden Rule Insurance Company, a UnitedHealthcare company, is the underwriter and administrator of these plans. With over 60 years of experience serving individuals and families, Golden Rule provides high-quality products, timely claims handling, and outstanding customer service.
Experience and Expertise
Golden Rule’s experience and expertise has driven the development of easy-to-use and innovative health insurance products. A recognized leader — and one of the nation’s largest providers of health savings account plans — Golden Rule continues building plans that meet the needs of individuals and families.
Our Goal: Your Satisfaction
We understand the importance of your time and concern for the value of your health-care dollars. You will find we go far beyond the industry average, processing an overwhelming majority of health insurance claims in less than two weeks and offering strong discounts when using our vast network of quality health-care providers. Our goal for every customer is an insurance plan at a price that fits his or her needs and budget. UnitedHealthOne — Choices you want. Coverage you need.
Leave it to the experts
For over 60 years, our experience and expertise in the individual health market has driven the development of plans that strive to make health coverage more affordable for more Americans. Because our primary focus is serving individuals and families, we understand the unique needs of people like you.
Don’t just take our word for it
Golden Rule is rated “A” (Excellent) by A.M. Best and “A+” (Strong) by Standard and Poor’s. These worldwide, independent organizations examine insurance companies and other businesses and publish their opinions about them. These ratings are an indication of our financial strength and stability.
Fast claims processing
We recognize the critical importance of being responsive to the service needs of our customers. That’s why more than 94% of all health insurance claims are processed within 10 working days or less.**
Big network, big savings
You can find many providers in your area with more than 580,000 physicians and care professionals and 4,900 hospitals nationwide in the UnitedHealthcare network.* Plus, our network can offer you provider discounts of up to 35-45% on quality health care.***
Initial rate guarantees
Benefit from securing your initial premium amount for 12 months with an option on all plans to extend up to 24 months.****
Benefits for a lifetime
Each of our plans gives you the protection of a $3 million lifetime benefit with an option to enhance your plan to a $5 million lifetime benefit.
Coverage for your children
Your children can benefit from coverage until they marry or until they reach the age of 26.
Get the specialized care you need
If you require care from a specialist, a referral is not required — making it easier for you to receive the care you need.
In case of emergency
From state to state, country to country -rest assured knowing that if you have a medical emergency coverage is available, even when travelling outside the U.S.
Membership has its benefits
FACT members have access to not only UnitedHealthOne health plans from Golden Rule, but also discounts on vision, dental, prescription drug, and even travel expenses. See the back cover of this brochure for more.
Deductible Credit
It can help you reduce your future out-of-pocket expenses. If you don’t meet your per-person calendar-year network deductible, the Deductible Credit applies to next year’s network deductible.
Each qualified covered person* not meeting the plan’s chosen Receives this credit for the network deductible** for: next calendar year:
1 year 20% of chosen network deductible 2 consecutive years 40% of chosen network deductible 3 or more consecutive years 50% of chosen network deductible
With a Health Savings Account plan (HSA 100 and HSA 70), the deductible credit will never reduce the deductible below the minimum required by law to maintain tax-qualified status of the insurance plan. The minimum for 2010 is $1,200 for singles and $2,400 for families.
With the optional Continuity rider, deductible credit is only received when a covered person is “active.”
Transplant Expense Benefit
The following types of transplants are eligible for coverage under the Medical Benefits provision:
Cornea transplants, artery or vein grafts, heart valve grafts, and prosthetic tissue replacement, including joint replacements and implantable prosthetic lenses, in connection with cataracts.
Transplants eligible for coverage under the Transplant Expense Benefit are:
Heart, lung, heart and lung, kidney, liver, and bone marrow transplants. Golden Rule has arranged for certain hospitals around the country (referred to as our “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 a transportation and lodging incentive (for a family member) of up to $5,000. Otherwise, the acquisition cost for the organ or bone marrow will not be covered, and covered expenses related to
the transplant will be limited to $100,000 and one transplant in a 12-month period. To qualify as a covered expense under the Transplant Expense Benefit,
the covered person must be a good candidate, and the transplant must not be experimental or investigational. In considering these issues, we consult doctors with expertise in the type of transplant proposed.
*Must be a covered person and in active status for six consecutive months.
The following conditions are eligible for bone marrow transplant coverage:
Allogenic bone marrow transplants (BMT) for treatment of: Hodgkin’s lymphoma or non-Hodgkin’s lymphoma, severe aplastic anemia, acute lymphocytic and nonlymphocytic leukemia, chronic myelogenous leukemia, severe combined immunodeficiency, Stage III or IV neuroblastoma, myelodysplastic syndrome, Wiskott-Aldrich syndrome, thalassemia major, multiple myeloma, Fanconi’s anemia, malignant histiocytic disorders, and juvenile myelomonocytic leukemia.
Autologous bone marrow transplants (ABMT) for treatment of: Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, acute lymphocytic and nonlymphocyctic leukemia, multiple myeloma, testicular cancer, Stage III or IV neuroblastoma, pediatric Ewing’s sarcoma and related primitive neuroectodermal tumors, Wilms’ tumor, rhabdomyosarcoma, medulloblastoma, astrocytoma, and glioma.
Notification Requirements
You must notify us by phone on or before the day a covered person:
- Begins the fourth day of an inpatient hospitalization; or
- Is evaluated for an organ or tissue transplant.
Failure to comply with Notification Requirements will result in a 20%
reduction in benefits, to a maximum of $1,000. If it is impossible for you to notify us due to emergency inpatient hospital admission, you must contact us as soon as reasonably possible.
Our receipt of notification does not guarantee either payment of benefits or the amount of benefits. Eligibility for and payment of benefits are subject to all terms and conditions of the policy. You may contact Golden Rule for further review if coverage for a health-care service is denied, reduced, or terminated.
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 a covered person received medical advice or treatment within 24 months prior to the applicable effective date for coverage of the illness or injury; or (b) which manifested symptoms which would cause an ordinarily prudent person to seek diagnosis or treatment within 12 months prior to the applicable effective date for coverage of the illness or injury.
**For family HSA plans, when combined per family deductible is not met. Mar 11 2010 04:38:48
Provisions That Apply to All Plans (continued)
Limited Exclusion for AIDS or HIV-Related Disease
AIDS or HIV-related disease are treated the same as any other illness unless the onset of AIDS or HIV-related disease is: (a) diagnosed before the coverage has been in force for one year; or (b) first manifested before the coverage has been in force for one year. If diagnosed or first manifested before coverage has been in force for one year, AIDS or HIV-related disease claims will never be covered. Details of this limited exclusion are set forth in the policy and certificates.
General Exclusions
No benefits are payable for expenses which:
• Are due to pregnancy (except for complications of pregnancy) or routine newborn care (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.
• Result from war, intentionally self-inflicted bodily harm (whether sane or 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 certificate is not in force.
• Are for any drug treatment or procedure that promotes
conception.
- Are for any procedure that prevents conception or childbirth.
- Result from intoxication, as defined by applicable state law in the state where the illness or injury 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/certificate, 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, subject to state variations). 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 certificate 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 a lifetime maximum of 365 visits. Registered nurse services are limited to a lifetime maximum of 1,000 hours.
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 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
- Becomes insured under an individual plan providing medical or
hospital, surgical, or medical services or benefits. (This does not
apply to stand-alone cancer, ICU, or accident-only policies.)
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 certificates 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. If you provide incorrect or incomplete information on your insurance application your coverage may be voided or claims denied.
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.
Group — COB
If, after coverage is issued, a covered person becomes insured under a group plan, benefits will be determined under the Coordination of Benefits (COB) clause. COB allows two or more plans to work together so that the total amount of all benefits will never be more than 100% of covered expenses. COB also takes into account medical coverage under auto insurance contracts.
Medicare — Carve-Out
Covered persons who reach the age of Medicare eligibility and obtain Medicare coverage may continue coverage under these plans. Benefits will be provided according to the Medicare Carve-Out Benefit Reduction provision. Basically, “carve-out” pays the difference between what Golden Rule benefits normally would pay and what is paid by Medicare.
Illinois Exclusions and Limitations
• A child will continue to be eligible after 26 if the child: is under age 30; is an Illinois resident; served in active or reserve branches of the U.S. Armed Forces, and received other than a dishonorable discharge.
