Who We Are
UniCare Life & Health Insurance Company (UniCare) is a WellPoint company. WellPoint, Inc. is the largest health benefits company in the nation. WellPoint and its family of companies provide health coverage for over 34 million people. It is the top medical membership carrier in the United States.

What We Deliver
· A nationally recognized insurance carrier with long established reliability and financial security
· An expansive network of independently contracted doctors, hospitals, and surgical centers
· Access to quality professional medical services at UniCare’s negotiated discounted fees
· A choice of affordable health insurance plans with coverage levels and pricing adaptable to your needs, budget and lifestyle

This Individual Short-Term (limited duration) health insurance plan with preferred provider (PPO) benefits features a $2 million per member lifetime maximum in benefits.

This plan offers the immediate coverage you need:
· Between jobs
· After graduation
· While waiting for permanent coverage

The power to choose:
· Coverage from 30 to 180 days
· Any day of the month to begin or end coverage
· Preferred deductible from $250 to $2,000

Maximum Coverage Period
You decide how long you need coverage with your UniCare Short-Term Plan. This plan is non-renewable and designed to meet your temporary health insurance needs while you are waiting for permanent coverage. After your Short-Term Plan expires, you may complete a new application and reapply for a new Short-Term Plan with a new deductible to be satisfied. However, after you have completed two coverage periods of a Short-Term Plan with less than six months lapse in between, you must wait six months to be eligible to apply for another Short-Term Plan.

Eligibility and Enrollment
Pricing is based on a per member, per day rate. Please remit your check for the entire premium with your application. For faster service, you may also choose to pay by credit card (VISA, MasterCard or Discover) and submit your application via fax. Your coverage will begin once your application has been approved by UniCare.

To qualify for coverage, you must be:
· At least 15 days old and under age 65;
· A resident of Texas; and
· A resident of the United States for at least six months.

To qualify for coverage, your dependents must be:
· Your lawful spouse of the opposite sex under age 65;
· Your unmarried child(ren) between the ages of 15 days and 25 years; or
· Your unmarried stepchildren between the ages of 15 days and 25 years; or
· Your unmarried adopted child or a child whom you are in the legal process of adopting; or
· Your unmarried grandchild(ren) between the ages of 15 days and 25 years if they are your dependents for federal income tax purposes at the time of application.

Please note that no dependents or newborns can be added once the plan is issued.

Effective Date of Coverage
Your effective date is determined by the date you choose to start coverage in accordance with the terms of the plan and acceptance by UniCare. Assuming UniCare’s acceptance, in most cases plans will take effect at 12:01 a.m. on the date following the U.S. Postal Service postmark date stamped on the envelope or receipt date by UniCare. If you pay by credit card and submit your application via fax, coverage may become effective as early as 12:01 a.m. the next day. If you submit your application by fax, please do not mail your application to UniCare.

What The Plan Covers^*
· $2 million per person lifetime benefit
· Emergency care
· Hospitalization services
· Outpatient services
· Access to any doctor you choose
· Professional services including x-ray, lab, and office visits
· Prescription drugs

* These listings are an overview only. Refer to the Plan Booklet for a more detailed list of benefits, including limitations, exclusions, preservice and utilization review, authorization process and penalties that may apply. Only the actual plan provisions apply. UniCare reserves the right to amend the plan’s terms.

This matrix provides a brief description of some of the plan features and reflects UniCare's payment for covered expenses after applicable deductibles are met. When you use UniCare independently contracted, participating (in-network) providers, your costs are based on a UniCare negotiated rate that may often save you money. When you use nonparticipating (out-of-network) providers, your costs are based on charges deemed by UniCare to be reasonable for that service and area. Reasonable charges may be less than your provider’s billed charges and often result in higher costs to you.

1 All benefits (except prescription drugs) are subject to the plan’s deductible.
2 Until transferable to a participating hospital, then 50% subject to an additional $500 deductible per continuing hospital confinement once transferable.
3 Certain prescription drugs require prior authorization by UniCare.

The primary limitations and exclusions for the individual short-term (limited duration) health insurance plans described in this brochure are listed below. Please take a few moments to review this information. These listings are an overview only. A more detailed list of each plan’s limitations and exclusions can be found in the applicable Plan Booklet. Only the actual terms of the applicable policy will apply.

The following are the primary limitations that apply to these plans:

Infusion Therapy: Covered Expenses will not exceed: total parenteral nutrition (with or without lipids), $250 per day; antibiotics, average wholesale price (AWP)+$125 per day; chemotherapy, AWP + $150 per day; pain management, $125 per day; aerosol therapy, AWP + $70 per day; tocolytic therapy, $250 per day; special items, AWP; intravenous hydration, $75 per day.

Ambulance Services: Limited to a maximum covered expense of $750 per trip (air or ground).

Home Health: Limited to a combined maximum of 30 visits per insured, per plan term.

Skilled Nursing Facilities: Limited to a maximum covered expense of $200 per day, and 50 days per insured, per plan term.

Services for Mental, Emotional or Functional Nervous Disorders: Benefits for eligible treatment are payable up to $30 per visit up to a maximum of 6 visits per insured, per plan term for in- or outpatient professional charges. Benefits for eligible inpatient hospital services are paid up to $100 per day, up to a maximum payment of $2,500 per insured, per plan term.

Physical and Occupational Therapy/Medicine, and Acupuncture: Benefits are payable up to $30 per visit with a combined total maximum of 6 visits per insured, per plan term.

AIDS/ARC: Benefits for Acquired Immune Deficiency Syndrome (AIDS) and/or AIDS Related Complex (ARC) are limited to a maximum of $10,000 per insured.

Prescription Drugs: Benefits for Brand Name Prescription Drugs are limited to a maximum payment of $1,000 per insured, per plan term.

These plans do not provide benefits for:
· Surgical procedures for sterilization (i.e., vasectomy, and/or tubal ligations).

· Any amount in excess of maximum amount of covered expenses.

· Services not specifically listed in the plan as covered services.

· Services or supplies that are not medically necessary as defined by UniCare.

· Services or supplies that are experimental or investigative.

· Services received before the effective date of coverage or during an inpatient stay that began before that effective date.

· Services received after coverage ends.

· Services for which you have no legal obligation to pay, or for which no charge would be made if you did not have health plan or insurance coverage, except to the extent that the availability of insurance or health plan coverage may be considered by a tax supported institution of the state of Texas providing treatment of mental illness or mental retardation to determine if a patient is non-indigent, as provided in Article 3196a of Vernon’s Texas Civil Statutes.

· Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits.

· Any intentionally self-inflicted injury or illness.

· Conditions caused by or contributed by (a) an act of war, (b) the inadvertent release of nuclear energy when government funds are available for treatment of illness or injury arising from such release of nuclear energy, (c) an insured person participating in the military service of any country, (d) an insured person participating in an insurrection, rebellion, or riot, (e) services received for any condition caused by an insured person’s commission of, or attempt to commit a felony, (f) an insured person, age 19 or older, being under the influence of illegal narcotics or non-prescribed controlled substances unless administered on the advice of a physician.

· Any services for which payment may be obtained from any local, state or federal government agency except: (a) when payment under this plan is expressly required by federal or state law; or (b) services provided for the treatment of mental or nervous disorders by a tax supported institution of the state of Texas.

· Any services to the extent that you receive Medicare benefits for those services. Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration hospitals and military treatment facilities will be considered for payment according to current legislation.

· Professional services received or supplies purchased from yourself, a person who lives in the insured person's home or who is related to the insured person by blood, marriage or adoption, or the insured person’s employer.

· Inpatient or outpatient services of a private duty nurse.

· Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.

· Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.

· Treatment of drug, alcohol, or other substance addiction or abuse.

· Dental services, including dental services for temporomandibular joint dysfunction.

· Orthodontic Services, including orthodontic services for temporomandibular joint dysfunction.

· Dental implants.

· Hearing aids.

· Routine hearing tests.

· Optometric services.

· An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or far sightedness (presbyopia).

· Outpatient speech therapy.

· Any drugs (including, but not limited to drug samples), medications, or other substances dispensed or administered in any outpatient setting unless otherwise covered by the plan.

· Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to medically necessary reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or to breast reconstruction performed to restore or achieve breast symmetry incident to a mastectomy and abnormal craniofacial structure caused by congenital defects.

· Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.

· Treatment of sexual dysfunction, impotence and/or inadequacy.

· All services related to the evaluation or treatment of fertility and/or infertility.

· All non-prescription contraceptive drugs, devices and supplies, and non-FDA approved prescription contraceptive drugs, devices and supplies. Prescription contraceptive drugs or devices are covered under the prescription drug benefit of this plan.

· Charges for pregnancy and maternity care including, but not limited to, normal delivery, elective cesarean sections, and elective abortions.

· Cryopreservation of sperm or eggs.

· Orthopedic shoes or shoe inserts, including orthotics (except when joined to braces or therapeutic footwear for the prevention of complications associated with diabetes).

· Services primarily for weight reduction or treatment of obesity.

· Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority.

· Charges by a provider for telephone consultations. (Note: a Telemedicine Medical Service or Telehealth Service will not be excluded solely because the service is not provided through a face to face consultation.)

· Items that are furnished primarily for your personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).

· Educational services except for diabetes self-management training programs, and as specifically provided or arranged by UniCare.

· Nutritional counseling or food supplements, except for formulas necessary for the treatment of phenylketonuria and medical nutrition care for diabetes.

· No benefits will be provided for any services received for a pre-existing condition.

· All incidental supplies used by a provider in the administration of infusion therapy.

· All Foreign Country Provider charges are excluded under this plan except as specifically stated in the plan.

· Growth hormone treatment.

· Routine foot care.

· Charges for which we are unable to determine our liability because you or an insured person failed, within 90 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested or; (b) provide us with information we requested regarding the circumstances of the claim.

· Charges for the services of a standby physician.

· Charges for animal to human organ transplants.

· Smoking cessation programs and medications.

· Services received from a hospice.

· Removal or treatment of hernia except for strangulated or incarcerated hernia.

· Treatment of varicose veins.

· Organ and tissue transplants.

Grievances
All complaints and disputes relating to your coverage must be resolved in accordance with UniCare’s grievance procedure. Grievances may be made by telephone or in writing; the phone number and address are located on your UniCare ID card. All grievances received by UniCare will be answered in writing, together with a description of how UniCare proposes to resolve the grievance.

Important Information Regarding HIPAA
Coverage under this Short-Term Plan may make a person ineligible for HIPAA guarantee issue coverage. To be eligible for a guarantee issue plan, a person must, among other things, have been most recently covered under an employer plan. This Short-Term Plan is not an employer plan. Additionally, enrollment in this Short-Term Plan may cause a person to lose credit toward subsequent pre-existing condition exclusions.

Cancellation Fee
Once your plan arrives, you have 10 full days to examine and either accept or decline coverage by returning the plan. After the 10-day free look period, you may cancel your plan by notifying UniCare in writing. Your cancellation will be effective 30 days after we receive your written notification. You will be charged a cancellation fee of $25 and the balance of the premium (if applicable) will be refunded to you

Additional Information
Please look online for information about permanent individual coverage options. Approved and enrolled Short-Term Plan members will receive a UniCare subscriber identification (ID) card and a Plan booklet. The Plan booklet gives a comprehensive description of what is covered.