Hospital & Doctor Fixed Indemnity Insurance

Health ProtectorGuard

Hospital & Doctor Fixed Indemnity Insurance

Predictable 1st dollar benefits for doctor care, hospital stays, and more

Table of Contents

Key Features & Network Doctor Visits Wellness/Preventive Care Pharmacy Services Outpatient Services Hospital Services

2 Surgical Services

8-9

3 Exclusions & Limitations

10

4 Insurance Plan Provisions 11

5 State Variations

12-13

6 Notice of Privacy Practices 14-16

7 Other Notices

17

This product provides limited benefits.

HEALTH PROTECTORGUARD IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.

This product provides benefits in a stated amount regardless of the actual expenses incurred.

Golden Rule Insurance Company is the underwriter and administrator of these insurance plans.

Policy Forms HPG2-GRI-01 (AL), HPG2-GRI-03 (AR), HPG2-GRI-09 (FL), HPG2-GRI-51 (HI), HPG2-GRI-12 (IL), HPG2-GRI-14 (IA), HPG2-GRI-17 (LA), HPG2-GRI-32 (NC), HPG2-GRI-26 (NE), HPG2-GRI-27 (NV), HPG2-GRI-35 (OK), HPG2-GRI-47 (WV), and HPG2-GRI-48 (WI)

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Health ProtectorGuard offers coverage with simple, straight-forward benefits for doctor visits, hospital stays and more. Design your coverage by selecting one of five insurance plans to fit your needs and budget.

Key features of these insurance plans:

? Choose any licensed doctor or hospital in the country.

? There is no lifetime maximum benefit.

? No coordination with other forms of insurance, which means you're paid a fixed amount for a covered service regardless of when or how other health insurance you may have pays the claim.

Save using MultiPlan's nationwide network

Health ProtectorGuard benefits are paid the same, regardless of which licensed providers you use.

You can save with discounts available through the MultiPlan Limited Benefit Plan Network. Multiplan offers access to more than 5,000 hospitals and 828,000 healthcare professionals.* Network providers have agreed to offer discounts on covered services which are reflected in your final bill. (Discounts for non-covered services are at the provider's discretion.) Discounted costs for services mean you may be able to reduce your out-of-pocket costs for medical services.

If you have a major medical plan, you may need to stay with certain networks and providers to get the most coverage out of that plan. Be sure to take that into consideration.

WELLNESS/ PREVENTIVE

PHARMACY SERVICES

OUTPATIENT SERVICES

DOCTOR VISITS

SURGICAL SERVICES

HOSPITAL SERVICES

How to receive benefits:

? In order for the MultiPlan Limited Benefit Plan Network discounts to apply, benefits must be paid directly to the provider. Ask your provider for the assignment of benefits form.

? Claims for covered services are submitted by the provider who is then paid by the insurance plan. If the payment is less than the claim amount, you pay the difference to the provider. If the payment is more than the claim amount, after the provider is paid, the remaining benefit is paid to you by check.

? Alternatively, you may submit a claim form for covered services you have paid, and we will reimburse you directly.

Note: A MultiPlan network flat fee of $3.25 per policy is charged per month. It is collected each month that the policy is in force and there is no pro-rating for a partial month. This fee is in addition to the premium you pay for the insurance plan.

Find Your Doctor Visit HealthProtectorGuard to see if your doctor is a part of the MultiPlan network. The MultiPlan Limited Benefit Plan Network is not insurance. It is a discount program only.

* Reference: MultiPlan Member Communication, 03/2017, Q1

This is an outline only and is not intended to serve as a legal interpretation of benefits. Reasonable effort has been made to have this outline represent the intent of contract language. However, the contract language stands alone and the complete terms of the coverage will be determined by the policy. State specific differences may apply, see pages 12-13.

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DOCTOR VISITS

Doctor Visits

? Regardless of the charge for your doctor visit we pay the set amounts below for eligible services.

? Urgent Care is provided at a medical facility providing immediate, non-routine urgent care for an injury or illness treated on a walk-in basis.

Why Health ProtectorGuard?

You have the freedom to choose a licensed doctor or hospital in the United States for your care. When you choose a provider who is part of the MultiPlan national network and assign your benefits, you will benefit from discounts on the services provided.

Doctor Visits

Office Visits/Urgent Care Visits for Injury or Illness: Benefit per visit (maximum per calendar-year) Note: Benefits for illness has an initial 5-day waiting period.*

Second Surgical Opinion (maximum per calendar-year)

We pay: We pay:

Choice Value $100

(2 visits)

$250 (1 day)

Choice Plus Select Value Select Plus

$100 (2 visits)

$100 (5 visits)

$100 (5 visits)

h See rollover benefit details below. h

$250 (1 day)

$500 (1 day)

$500 (1 day)

Premier Plus $100

(5 visits)

$500 (1 day)

* Services received for injuries are eligible for coverage as of your insurance plan's effective date; services received for illnesses are eligible for coverage beginning on the 6th day following the effective date. Preexisting conditions apply. See page 11 for details.

Rollover Benefit

If you can rollover your unused data, why not your doctor visits too? This unique benefit allows you to rollover any unused doctor office (illness or injury) or urgent care visits remaining at the end of a calendar year to the next calendar year. A maximum of 5 visits are allowed to rollover.

If the effective date of coverage is prior to July 1, then any eligible unused visits may rollover on the following January 1. If the effective date is on or after July 1, then unused visits cannot begin accruing until January 1 following 12 consecutive months of coverage.

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WELLNESS/ PREVENTIVE

Wellness/Preventive Care

? A Wellness/Preventive care visit is eligible after a 6-month waiting period. ? Regardless of the charge for your doctor visit we pay the set amount

below.

Why Health ProtectorGuard?

These insurance plans are guaranteed renewable to age 65. You and your family cannot be singled out for a rate increase or cancellation based on changes to your health alone. See page 11 for more details.

Plans:

Wellness/Preventive Care Benefit Wellness/Preventive Care Day (maximum per calendar-year after initial 6-month waiting period)

HPG2 SI 1 HPG2 SI 3

We pay:

Choice Value

$100 (1 day)

Choice Plus

$100 (1 day)

HPG2 SI 3

Select Value $200 (1 day)

HPG2 SI 4 HPG2 SI 5

Select Plus

$200 (1 day)

Premier Plus

$250 (1 day)

According to the Centers for Disease Control and Prevention, "If everyone in the US received recommended clinical preventive care, we could save over 100,000 lives each year. Preventive health care can help you stay healthier throughout your life."

-- Centers for Disease Control and Prevention, Office of the Associate Director for Policy - Prevention, December 23, 2015

Wellness/Preventive Care

Services eligible under this benefit may include the following: annual physicals, immunizations (other than a flu shot), mammograms, and blood screenings.

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PHARMACY SERVICES

Pharmacy Benefits

? Name Brand and Generic medication benefits on select insurance plans. ? A Prescription Drug Discount Card is included with all insurance plans.

Why Health ProtectorGuard?

Golden Rule Insurance Company is rated "A" (Excellent) by A.M. Best, a widely recognized rating agency that rates insurance companies on their relative financial strength and stability. (06/30/16)

Pharmacy Services

Prescription Drugs (Per Rx fill)

Maximum Rx Fills Per calendar-year (Combined Brand and Generic)

We pay:

Choice Value Discount Card

only

N/A

Choice Plus Generic: $20 Brand: $40

12

Select Value Discount Card

only

N/A

Select Plus Generic: $20 Brand: $40

12

Premier Plus Generic: $20 Brand: $40

12

Prescription Drug Discount Card

A National Prescription Savings Network (NPSN) discount card is automatically included with every insurance plan and is free for you and your dependents to use. Most U.S. pharmacies honor this card offering savings of up to 50-75%. The card is pre-activated and ready to use upon receipt. The card can be used even if the insurance plan you selected does not offer prescription benefits. The NPSN card is not insurance. It is a discount program only.

How to receive benefits:

? Every time you get a prescription, give the pharmacist your card and ask for discounts on your prescription drugs.

? You pay the pharmacy directly and, if your insurance plan provides prescription benefits, submit a claim form for reimbursement.

? Reimbursement is paid directly to you and you receive the applicable benefit amount based on the insurance plan you selected and type of prescription drug (generic or brand). A listing of covered drugs is available online at UHO or by calling 1-877-890-8077.

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