Copyright © 2005 Golden Rule Insurance Company                          Health insurance available only to members of FACT

Policy Forms C-006.3 or C-006.4                                                                                                                                     35527HSA-0105


How HSAs Work


Traditional Insurance Premium $

It’s simple. The money you
save on premiums can be put
into your tax-advantaged
savings account. Those
savings can help pay your
deductible or other qualified
medical expenses tax-free.
After the deductible is met,
the insurance starts paying.



HSAs offer quality coverage, savings

HSAs have two components: a lower cost, high deductible health insurance plan to provide coverage for your larger medical expenses, and a tax-favored savings account.

 

The idea is really simple. The money you save on premiums can be put into your tax-favored savings account, and then withdrawn to help pay your deductible or pay for other qualified medical expenses.

 

You own your savings account. You make the decisions on how and when to spend the money.

 

Your unspent health care savings roll over year after year. In other words, you won’t lose what you don’t spend in any given year.

 

And if used for medical care now or after retirement, the money in your savings account will never be taxed.

 

Plus, Golden Rule credits interest on the money in your savings account.

Lower premiums, tax-deferred savings, network discounts, and an attractive interest rate

Now, it all adds up. The money you save from

reduced premiums can be put into your Health Savings Account -- tax-deferred.

 

On top of that, at Golden Rule, you’ll earn annual interest on your savings, beginning with the first dollar deposited.

 

Your health savings grow tax-deferred, and can be withdrawn tax-free to help pay your deductible or to pay for other qualified medical expenses like prescriptions, vision, or dental care.

 

What you don’t use will continue to accumulate year after year. Then, if you ever need it for medical expenses, the money will be there.

 

That’s good planning and extra peace of mind when you need it most. And you’re in control.


Text Box: 3Health Savings Account

(HSA) Plans                     Benefit Highlights

Design Basics

Plan Type

HSA 100SM                  NEW! HSA SaverSM

Preferred or Savings Based Network

Deductible Choices

See page 4 for details

See page 4 for details

Coinsurance After Deductible

100%

100%

Lifetime Maximum Benefit

(per covered person)

$3 million

$3 million

Initial Rate Guarantee

(subject to benefit and address changes)

12 months

12 months

Coverage percentages below are effective AFTER

Inpatient Expense Benefits

Room and Board, Intensive Care Unit,

Operating Room, and Recovery Room

deductibles have been met unless

100%

otherwise indicated.

100%

Professional Fees of Doctors, Surgeons, Nurses

100%

100%

Radiation, Chemotherapy, and Inpatient Drugs

100%

100%

Inpatient Diagnostic Testing

100%

100%

Other Covered Inpatient Services

Outpatient Expense Benefits

Surgeon, Assistant Surgeon, and Facility Fees

100%

100%

100%

100%

Hemodialysis, Radiation, Chemotherapy,

and Organ Transplant Drugs

100%

100%

Cat Scans, MRIs

100%

100%

Outpatient X-ray and Lab

100%

100% if performed within 14 days

 

 

of surgery or confinement

Emergency Room Fees

100%

100% if admitted; if not admitted -‑

limited to $250/person/year

Other Covered Outpatient Expenses

Routine Health Benefits

Doctor Office Visit Fees

100%

100%

See page 8 for details

Not Covered

Outpatient Prescription Drugs

(Preferred Price Card included with all plans)

100%

Not Covered -‑

Preferred Price Card Included

Mammography, Pap Smear, and PSA Testing

100%

100%

Adult Preventive Care (Up to $500 annually for each adult

age 19 or older; subject to 3-month waiting period)

100%

Not Covered

Childhood Immunizations (Up to $500 annually for ages

0-18; subject to 3-month waiting period)

100%

Not covered

Dental and Vision Discounts --

Programs Are Not Insurance

Discounts through Health Allies (benefit of FACT membership) -‑

save up to 50% on dental and vision.

Optional Benefits

For a complete list, see page 6. NEW! Preventive Care Benefits

Package -- see page 6. Hospital Indemnity Rider -- see page 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 8-12, and the state variations on pages 13 and 14.



Health Savings Accounts (HSAs) -- Summary of the Law


Effective Date -- Tax years beginning after December 31,      Medical Withdrawals -- Tax-free

 
 



Text Box: 2003Eligibility -- Those covered under a qualified high deductible health plan, and not covered by other health insurance or enrolled in Medicare

HSA Contributions -- 100% tax-deductible from gross income


Interest Earned -- Tax-deferred; if used for qualified medical expenses, tax-free

Non-medical Withdrawals -- Income tax +10% penalty tax (under age 65); income tax only (for age 65 and over)

Death, Disability -- Income tax only -- no penalty


Deductible and out-of-pocket maximums may be adjusted annually based on changes in the Consumer Price Index. This is only a brief summary of the applicable federal law. Consult your tax advisor for more details of the law.


Why Choose Golden Rule?


Experience and Expertise

Golden Rule has been a leader in the individual health market for nearly 60 years. Serving individuals and families is our primary focus. Because we are dedicated to this market, we have developed a unique understanding of the health insurance needs of individuals and families. This knowledge is reflected throughout your experience with Golden Rule -- in our high quality products, our handling of claims, and our customer service.

 

Product Leadership

Golden Rule’s experience and expertise in the individual health market drive the development of plans that strive to make health coverage more affordable for more Americans. A recognized pioneer -- and one of the nation’s leading providers -- of Health Savings Accounts, Golden Rule continues to seek and embrace new ways to build plans with the benefits you need at prices you can afford.

 

Claims Satisfaction

At Golden Rule, we recognize the critical importance

of being responsive to the service needs of our customers. That’s why more than 94 percent of all health insurance


claims are processed within 10 working days or less.* With Golden Rule, you can be confident that your claims will be promptly processed.

 

Preferred Network Discounts

With a Golden Rule insurance plan, you gain access to a quality network of health care professionals and facilities available in your area. Having access to our Preferred Networks can mean substantial discounts in what you pay for your health care. The combined buying power of networks on behalf of large numbers of customers can translate into significant savings for you, including covered out-of-pocket medical expenses incurred before you meet your deductible.

 

Strength in Numbers

Golden Rule is proud to be a member of the UnitedHealth Group family of businesses. As an innovative leader in the health and well-being industry, UnitedHealth Group currently serves nearly 55 million individuals nationwide, with products and services to help people achieve better health.

 

* Actual 2004 results


World of FACT Value


Text Box: Plus …
•	You may apply for: FACT scholarships, classroom grants, and com¬munity project grants
Text Box: • You are eligible to request: Financial assistance in the event of a natural disaster
•	You are kept aware of matters of importance through:
FACT’s Eye -On -Washington Reports
These health insurance plans are available as group coverage only to members of FACT. If you’re not already a member, you must join FACT. When you join FACT and sign up for insurance with Golden Rule, you enjoy group benefits and maintain your independent status!

World of FACT Value

FACT makes it possible for members to pick and choose from a full menu of important benefits:

·       Dental Discounts -- you can save up to 50% on general dental, x-rays and orthodontics

·       Vision discounts -- typical savings of 20-60% for eye exams, eye­glasses, contact lenses and LASIK correction surgery

·       Prescription drug discounts

·       Van line discounts

·       Health insurance plans


·    Consumer library

·    Consumer hotline referral service

·    Amusement park discounts

·    Travel service and savings

·    Informative newsletter



Health Care Provider Networks


All Golden Rule health insurance plans include access to one of our Savings-Based Networks. Preferred Networks are also available, and offer significant premium discounts.

Savings-Based Networks

Savings-Based Networks are included with all plans and provide:

·      Access to a broad network of physicians and hospitals to help reduce your costs; and

·      Freedom to use non-network physicians and hospitals if Savings-Based Network providers aren’t available in your area.

 

While you are free to use any health care professional, using a Savings-Based Network physician or hospital benefits you in the following ways:

·      You may pay less for services incurred before your deductible is met;

·      Network physicians and hospitals will not bill above the accepted network fee; and

·      Network physicians and hospitals will file your claim for you.


Preferred Networks

Available in most areas. A Preferred Network includes physicians, hospitals, and other health care providers that have agreed to provide quality health care at reduced costs.

 

Lower costs means lower premiums. Most applicants choose one of our Preferred Networks to take advantage of these premium reductions.

 

In return for the premium reduction, you agree to use physicians, hospitals, and other health care providers in your Preferred Network.

 

If you are insured under a Preferred Network plan and receive non-emergency services outside your Preferred Network, covered expenses are:

·      Reduced by 25%; and

·      Subject to a separate deductible amount equal to the calendar-year deductible.



 


Covered Expenses

Subject to all policy provisions, the following expenses are covered.

HSA SaverSM


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 if followed by confinement. Air ambulance, within US, if requested by police or medical authorities at the site of 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 page 3).

·      CAT scan and MRI testing.

·      Diagnostic testing related to, and performed within, 14 days prior to surgery or inpatient confinement.

 

Important note about Saver Plans:

Premiums for Saver Plans are significantly less because coverage is not provided for most outpatient services. Outpatient expenses not specifically listed in the policy are not covered. Please review the Saver Plans’ inpatient and outpatient expense benefits, exclusions, and limitations for details.

 

Some outpatient expenses not covered under the Saver Plans include:

·   Outpatient doctor office visit fees, diagnostic testing, prescription drugs, and other outpatient medical services not specifically listed under the Medical Benefits or Transplant Expense Benefits;

·   Outpatient professional fees of licensed physical therapists, durable medical equipment, and medical supplies, except those covered under the Home Health Care Expense Benefits;

·   Outpatient expenses incurred for mental or nervous disorders or substance abuse; and

·   Preventive care office visits (unless the optional Preventive Care Package is added).


Covered Expenses (continued)

Subject to all policy provisions, the following expenses are covered.

H SA 100SM


Medical Expense Benefits

·      Daily hospital room-and-board and nursing services at the most common semiprivate rate.

·      Charges for intensive care unit.

·      Surgery at an outpatient surgical center.

·      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 US, 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 11).

·      Cost and administration of anesthetic, oxygen, and other gases.

·      Radiation therapy or chemotherapy.

·      Prescription drugs.

·      Hemodialysis, processing, and administration of blood and components.

·      Mammography, pap smear, and PSA test fees.

·      Artificial eyes, larynx, breast prosthesis, or basic artificial limbs (but not replacements).

Preventive Care Expense Benefits

·      See page 3 for coverage details.

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 10-12.


Text Box: Provisions That Apply to All Plans
0


 

 

 

 


Health Care Provider Networks

All Golden Rule plans include access to one of our Savings-Based Networks. Preferred Networks are also available, and offer significant premium discounts. See page 7 of this brochure for more information.

 

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.

 

Home Health Care

To qualify for benefits, home health care must be:

·   Provided in lieu of medically necessary inpatient care in a hospital or hospice; and

·   Provided through a licensed home health care agency.

Covered expenses for home health aide services will be limited to seven visits per week, and a lifetime maximum of 365 visits. Registered nurse services will be 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 will be 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.

 

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 percent 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 which 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 and HIV-related disease is 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 and 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).

·      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 employment-related injury or illness if the covered person is insured or is required to be insured, by workers’ compensation insurance under applicable state or federal law.

·      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.

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, will not be 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 which 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 ten­year period.

·      Charges for an assistant surgeon are limited to 20 percent of the primary surgeon’s covered fee.

·   Covered expenses for surgical treatment of TMJ,

excluding tooth extractions, will be limited to $10,000 per covered person.


·   All diagnoses or treatments of mental disorders, as defined in the policy, including substance abuse, will be limited to a lifetime maximum benefit of $3,000. Covered expenses for outpatient diagnosis or treatment of mental disorders will be further limited to $50 per visit. As with any other illness or injury, inpatient care which is primarily for educational or rehabilitative care will not be covered.

·   Covered outpatient expenses relating to diagnosis or treatment of any spine or back disorders will be limited to a maximum of $2,000 per calendar year. CAT scan and MRI tests are not subject to this limitation.

·   Covered expenses will be 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 at its Home Office.

For an application sent by any electronic method, 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 at its Home Office.

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 a preexisting condition 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.

 

Dependents

For purposes of this coverage, eligible dependents are your lawful spouse and eligible children. Eligible children must be unmarried, living with and financially dependent on you, and under 19 years of age, or under 23 years of age if attending an accredited college or vocational school on a full-time basis.


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, 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.

 

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 percent 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 will be provided an alternative health insurance benefit called “Carve-out.” Basically, “Carve-out” pays the difference between what Golden Rule benefits normally would pay and what is paid by Medicare.