UHC Short Term Health Insurance

The following medical benefits are provided using network providers and are subject to all policy provisions, the deductible, and any applicable copay or coinsurance (unless otherwise stated). You will find complete coverage details in the policy.

Ambulance Services Ground ambulance service to a hospital for necessary emergency care. Autism Spectrum Disorders Outpatient applied behavior analysis limited to $50,000 per policy term, per covered person. Dental Services Dental expenses for an injury to natural teeth suffered after the coverage effective date. Expenses must be incurred within 6 months of the accident. No benefits payable for injuries due to chewing as limited in the policy. Diabetes Diabetes equipment, supplies, and services.

• Diabetes self-management training when medically necessary as determined by a physician, prescribed by a physician, and provided by an appropriately licensed health care professional limited to:
  • One diabetes self-management training program per covered person, per lifetime.
  • Additional diabetes self-management training prescribed by a physician as medically necessary due to a significant change in the covered person’s symptoms or condition.

Durable Medical Equipment Rental of wheelchair, hospital bed, and other durable medical equipment. Home Health Care Home health care prescribed and supervised by a doctor and provided by a licensed home health care agency. Covered expenses for home health aide services will be limited to 7 visits per week and a lifetime maximum of 365 visits. Benefits for home health care will not extend beyond the term of your plan. Each 8-hour period of home health aide services will be counted as one visit. Private duty registered nurse services will be limited to a lifetime maximum of 1,000 hours. Intermittent private duty registered nurse visits are not to exceed 4 hours each and are limited to $75 per visit (2 hours per visit are applied toward the lifetime maximum of registered nursing). No benefits payable for respite care, custodial care, or educational care. Hospital Services Daily hospital room and board at most common semiprivate rate; eligible expenses for an intensive care unit; inpatient use of an operating, treatment, or recovery room; outpatient use of an operating, treatment, or recovery room for surgery; services and supplies, including drugs and medicines, which are routinely provided in the hospital to persons for use only while they are inpatients; emergency treatment of an injury or illness. Covered expenses for use of the emergency room are subject to a copayment of $250 for each emergency room visit. Hospital does not include a nursing or convalescent home or an extended care facility. Medical Supplies

• Dressings and other necessary medical supplies.
• Cost and administration of an anesthetic or oxygen.

Newborn Care

• • Pregnancy not covered, except for complications.
  • Routine in-hospital care of a newborn for the first five days or until the mother is released which ever occurs first.

Outpatient Surgery Physician Fees

• • Assistant surgeon fee for a doctor, limited to 20% of eligible expenses of the procedure, and 14% of eligible expenses of the procedure for another medical professional acting as an assistant surgeon.
  • Professional fees of doctors, medical practitioners, and surgeons.

Preventive Care

• • Colorectal cancer examinations, prostate-specific antigen testing, and other preventive care as required by your state and specified in the certificate.
  • Children’s preventive health services for covered children as defined in the certificate.

Rehabilitation and Extended Care Facility (ECF) Must begin within 14 days of a 3-day or longer hospital stay for the same illness or injury. Limited to 60 days per policy term for both rehabilitation and ECF expenses. Spine and Back Disorders Benefits for treatment of spine and back disorders limited to $250 per person, per policy term. Therapeutic Treatments Radiation therapy and chemotherapy.

• • Hemodialysis, processing, and administration of blood or components (but not the cost of the actual blood or components).

Transplant Expense 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 transplants per policy term, 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.

Indiana Specific Information:

C-016.1

Application fee is refundable.

• • The definition of preexisting condition is replaced with: “Preexisting condition” means a condition for which the covered person received medical advice or treatment within the 12 months immediately preceding the date he or she became insured under the policy.

This is only a general outline of the coverage provisions and exclusions. It is not an insurance contract, nor part of the insurance policy/certificate. You will find complete coverage details in the policy/certificate  General Exclusions Benefits will not be paid for services or supplies that are not administered or ordered by a doctor and medically necessary to the diagnosis or treatment of an illness or injury, as defined in the policy. No benefits are payable for expenses:

• • For non-emergency services or supplies received from a provider who is not a network provider, except as specifically provided for by the policy.
  • 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.

• NOTE: Even if you have had prior Golden Rule coverage and your preexisting conditions were covered under that plan, they will not be covered under this plan.
• That would not have been charged if you did not have insurance.
• Incurred while your coverage is not in force.
• Imposed on you by a provider (including a hospital) that are actually the responsibility of the provider to pay.
• For services performed by an immediate family member.
• That are not identified and included as covered expenses under the policy/certificate or are in excess of the eligible expenses.
• For services that are not covered expenses.
• For services or supplies that are provided prior to the effective date or after the termination date of the coverage.
• For weight modification or surgical treatment of obesity, including wiring of the teeth and all forms of intestinal bypass surgery.
• For breast reduction or augmentation.

• For drugs, treatment, or procedures that promote conception.
• For sterilization or reversals of sterilization.
• For fetal reduction surgery or abortion (unless life of mother would be endangered).
• For treatment of malocclusions, disorders of the temporomandibular joint (TMJ) or craniomandibular disorders.
• For modification of the physical body in order to improve psychological, mental, or emotional well-being, such as sex-change surgery.

• Not specifically provided for in the policy, including telephone consultations, failure to keep an appointment, television expenses, or telephone expenses.
• For marriage, family, or child counseling.
• For standby availability of a medical practitioner when no treatment is rendered.
• For hospital room and board and nursing services if admitted on a Friday or Saturday, unless for an emergency, or for medically necessary surgery that is scheduled for the next day.
• For dental expenses, including braces and oral surgery, except as provided for in the policy/certificate.
• For cosmetic treatment.
• For reconstructive surgery unless incidental to or following surgery or for a covered injury, or to correct a birth defect in a child who has been a covered person since childbirth until the surgery.
• For diagnosis or treatment of learning disabilities, attitudinal disorders, or disciplinary problems.
• For diagnosis or treatment of nicotine addiction.
• For charges related to, or in preparation for, tissue or organ transplants, except as expressly provided for under Transplant Services.
• For high-dose chemotherapy prior to, in conjunction with, or supported by ABMT/BMT, except as specifically provided under the Transplant Expense Benefits provision.

No benefits are payable for expenses:

• • For eye refractive surgery, when the primary purpose is to correct nearsightedness, farsightedness, or astigmatism.
  • While confined for rehabilitation, custodial care, educational care, nursing services, or while at a residential treatment facility, except as provided for in the policy/ certificate.
  • For eyeglasses, contact lenses, hearing aids, eye refraction, visual therapy, or any exam or fitting related to these devices, except as provided for in the policy/ certificate.
  • Due to pregnancy (except complications), except as provided in the policy/certificate.
  • For diagnostic testing while confined primarily for well-baby care, except as provided in the policy/certificate

• • For treatment of mental disorders or substance abuse including court-ordered treatment for programs, except as provided in the policy/certificate.
  • For preventive care or prophylactic care, including routine physical examinations, premarital examinations, and educational programs, except as provided in the policy/ certificate.
  • Incurred outside of the U.S., except for emergency treatment.
  • Resulting from declared or undeclared war; intentionally self-inflicted bodily harm (whether sane or insane); or participation in a riot or felony (whether or not charged).
  • For or related to durable medical equipment or for its fitting, implantation, adjustment or removal or for complications therefrom, except as provided for in the policy/certificate.
  • For outpatient prescription drugs, except as provided for in the policy/certificate.
  • For surrogate parenting
  • For treatments of hyperhidrosis (excessive sweating).
  • For alternative treatments, except as specifically covered by the policy/certificate, including: acupressure, acupuncture, aromatherapy, hypnotism, massage therapy, rolfing, and other alternative treatments defined by the Office of Alternative Medicine of the National Institutes of Health.
  • If you entered into a settlement that waives your right to recover future medical benefits under a workers’ compensation law or insurance plan, this exclusion will still apply.
    • Resulting from intoxication, as defined by state law where the illness or injury occurred, or while under the influence of illegal narcotics or controlled substances, unless administered or prescribed by a doctor.
    • For joint replacement, unless related to an injury covered by the policy/certificate.
    • For non-emergency treatment of tonsils, adenoids, hemorrhoids or hernia.
    • For injuries sustained during or due to participating, instructing, demonstrating, guiding, or accompanying others in any of the following: sports (professional, or semi-professional, or intercollegiate except for intramural), parachute jumping, hang-gliding, racing or speed testing any motorized vehicle or conveyance, scuba/skin diving (when diving 60 or more feet in depth), skydiving, bungee jumping, or rodeo sports.
    • For injuries sustained during or due to participating, instructing, demonstrating, guiding, or accompanying others in any of the following if the covered person is paid to participate or to instruct: operating or riding on a motorcycle, racing or speed testing any non-motorized vehicle or conveyance, horseback riding, rock or mountain climbing, or skiing.
    • For injuries sustained while performing the duties of an aircraft crew member, including giving or receiving training on an aircraft.
    • For vocational or recreational therapy, vocational rehabilitation, or occupational therapy, except as provided for in the policy/certificate.
    • Resulting from experimental or investigational treatments, or unproven services.

    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.