United Health Care – North Carolina

UnitedHealthcare North Carolina

More than 26 million customers entrust UnitedHealthcare with their health insurance needs.* Our 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.

North Carolina is no different.  United Health One offers a full selection of plans to the North Carolina health insurance market and to see which plans fit your needs get a United Health Care North Carolina health insurance quote now.

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.

Copay Select Plans in North Carolina

Convenient Doctor Office Copay Benefits

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

Adult and Child Preventive Care Included

After a 3-month waiting period, you pay $35 for the doctor office visit with Copay SelectSM. X-rays and lab tests are covered after you pay your chosen coinsurance (0%, 20%, or 30%).

Prescription Drug* Card Benefits (Copay SelectSM Only)

  • Tier 1 drugs — $15 copay.
    • Tier 2-4 drugs — combined $200 deductible per person, per calendar year, then:
      • $35 copay for Tier 2 drugs.
      • $65 copay for Tier 3 drugs.
      • 25% coinsurance (you pay) for Tier 4 drugs.

Comprehensive Coverage for Inpatient and Outpatient Medical Expenses

(Copay SelectSM Only)

  • You choose $3 million or $5 million lifetime maximum benefit per covered person.
  • Covered inpatient and outpatient expenses are reimbursed after your chosen coinsurance and the deductible.

United Health One HSA Plans in North Carolina

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.

Adult and Child Preventive Care Included

With our HSA plans, after a 3-month waiting period, you pay a $35 copay (in-network) for the doctor office visit.

Bottom line — HSAs can help make

Traditional Insurance High Deductible Insurance Premium Savings $

North Carolina High Deductible Plans

Lower Premiums

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 80SM is our lowest premium plan. This plan provides coverage for hospital confinements, surgical procedures in or out of the hospital (but not in the doctor’s office), 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 80SM include preventive care and child immunizations with no waiting period.

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.

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.

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.

Mar 11 2010 11:31:08

Provisions That Apply to All Plans (continued)

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.

Mar 11 2010 11:31:08

Provisions That Apply to All Plans (continued)

• 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.

North Carolina

• Nonsurgical treatment of TMJ is provided, up

to a lifetime maximum of $3,500.

• The lifetime maximum for surgical treatment of TMJ does not apply.

• Portability plans (guarantee issue without preexisting conditions exclusions) are available to eligible applicants. Review the application for insurance for details.

• Occupational injuries or illnesses are not

covered expenses if paid under the North

Carolina Workers’ Compensation Act.

• The preexisting conditions reference to treatment within 24 months prior to the applicable effective date is changed to 12 months. This 12-month waiting period may be reduced for persons covered by qualifying prior coverage.

• The limited exclusion for AIDS does not apply.

• Nonemergency care provided out-of-network will be: reduced by 25% of the in-network benefit paid rather than 25% of the covered expense. (Still subject to reasonable and customary charges; and an additional deductible amount equal to the per person, calendar-year deductible.)

• Send medical claims to: Golden Rule Insurance Company 7440 Woodland Dr. Indianapolis, IN 46278-1720