UniCare Sound - Curb Jumper - $3000 Deductible Health Insurance Plan for Illinois Residents

Sound Plans Limitations & Exclusions

The primary limitations and exclusions for these medical insurance plans are listed below. These listings are an overview only. A more detailed list of each plan’s limitations and exclusions can be found in the applicable certificate of coverage.

These plans do not provide benefits for:

Any amounts in excess of maximum amounts of covered expenses stated in the certificate of coverage
Services not specifically listed in the certificate of coverage as covered services
Services or supplies that are not medically necessary
Services or supplies that UniCare considers to be for experimental procedures or investigative procedures
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 a health policy or insurance coverage
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: (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 participating in the military service of any country; (d) an insured participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured’s commission of, or attempt to commit a felony or as a direct result of the insured being engaged in an illegal occupation; (f) an insured, being under the influence of illegal narcotics, alcohol or non-prescribed controlled substances unless administered under the advice of a physician.
Any services provided by a local, state or federal government agency, except when payment under the certificate of coverage is expressly required by federal or state law.
If you are eligible for Medicare, any services covered by Medicare under parts A or B are excluded regardless of actual enrollment in Medicare or payment by Medicare for those services. However, for any covered services, if there is a balance remaining after the Medicare payment, or the amount that Medicare would have paid had you enrolled in the program, UniCare will pay the remaining balance up to the Medicare allowable amount. In no event, however, will the actual amount UniCare pay exceed the amount that UniCare would have paid if it were the sole insurance carrier.
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’s home or who is related to the Insured by blood, marriage or adoption, or any of the insured’s employers.
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, or other substance addiction or abuse except as specifically stated in the certificate of coverage.
Dental services except as specifically provided in the certificate of coverage.
Orthodontic services.
Dental implants or associated procedures.
Hearing aids.
Routine hearing tests except as provided under Well Baby and Well Child Care.
Optometric services except as specifically stated in the certificate of coverage.
An eye surgery solely for the purpose of correcting refractive defects of the eye.
Outpatient speech therapy.
Any drugs, medications, or other substances dispensed or administered in any outpatient setting.
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 reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
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 except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies.
All services related to the evaluation or treatment of fertility and/or infertility.
All non-prescription contraceptive drugs, devices and/or supplies that are available over the counter or without a prescription, and non-FDA approved prescription contraceptive drugs, devices and/or supplies. FDA approved prescription contraceptive drugs or devices available through a licensed pharmacy are covered under the prescription drug benefit of this plan.
Cryopreservation of sperm or eggs.
Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
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.
Charges by a provider for telephone consultations.
Items which are furnished primarily for your personal comfort or convenience.
Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare.
Nutritional counseling or food supplements.
Any services received on or within 12 months after the effective date of coverage if they are related to a pre-existing condition.
Foreign Country Provider charges are excluded under this Plan except as specifically stated in the certificate of coverage.
Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured's condition.
Routine foot care.
Charges for which we are unable to determine our liability because you failed, within 60 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 or other insurance coverage.
Charges for animal to human organ transplants.
Charges for pregnancy or maternity care, including normal delivery, elective abortions or cesarean sections.
Claims received after 15 months from the date the service was rendered.

Medical Underwriting Requirement

UniCare believes in fairness, and the cost of covering someone with minimal health care needs should not be unfairly offset by someone whose health can be predicted to require costly care. That's why UniCare offers various levels of coverage, ensuring an overall balance of risk. To determine individual medical risk factors, all enrollments are subject to medical underwriting and approval by UniCare.

Depending on the results of underwriting review, a number of things may happen:
• you may be offered coverage at the preferred premium charge, or
• you may be offered the plan you selected at a higher rate, or
• you may not qualify for the plan applied for, but may be offered to apply for an alternative plan, or
• you may not qualify for the plan applied for, or an alternative plan, an your application will be rejected.

Terms of Coverage

Coverage under the health insurance plan will remain in force as long as you pay the required premium. Coverage will cease in the following situations: when the required premiums are not paid on time; when you move out of the state; or in the case of fraud, intentional misrepresentation of materials fact, or if UniCare no longer offers plans of this type or if UniCare ceases offering any individual plans in Illinois to all insureds in your class.

Rates

Rates are based on the age of the applicant, the residence address and undewriting classification. Rates are recalculated at each billing period based on age and the residence address. Any initial rate guarantees offered under these plans do not include age-banded or area rate changes. UniCare may change the premiums of this plan with 30 days prior written notice to you. However, UniCare will not change rates unless the change applies to all covered persons under the same plan and same class.

Emergency

If you reasonably believe a medical emergency exist, no utilization or authorization is required. A medical emergency is an unexpected acute illness, injury, or condition that could endanger your health if not treated immediately. Once your condition is stabilized, it is important for the hospital, you, or your family member to contact UniCare for authorization of additional services.

10-Day FREE Look

Once your Certificate of Coverage arrives, you have 10 full days to examine and either accept or decline coverage by returning the Certificate of Coverage along with a letter notifying UniCare that you wish to discontinue coverage.

Waiting Periods

An insured person must be covered for six consecutive months under this plan to be eligible for benefits concerning all services related to:

• Hernia except for strangulated or incarcerated hernia
• Varicose veins

This includes, but is not limited to, all tests, consultations, examinations, medications, and invasive medical laboratory or surgical procedures that are related to the evaluation or treatment of the above items.

Pre-Existing Conditions

Coverage will not be provided for the 12 months following the effective date of this plan for medical conditions that existed in the 12 months prior to the effective date.

Utilization Management and Authorization Program

UniCare uses a process called Utilization Management to help you receive coverage for appropriate treatment in the correct setting and helps you avoid both unexpected out-of-pocket costs and unnecessary procedures.

Utilization review may take place prior to admission to a hospital or ambulatory surgical center. You must initiate utilization review at least three working days prior to admission. Failure to obtain utilization review prior to services being rendered may result in additional penalties. There are certain other services that require prior authorization to be eligible for maximum benefits. Refer to the Benefits Summary list of specific penalty amounts. Also see your Certificate of Coverage for additional details on preservice review and utilization review, penalties, the authorization program, covered services, and limitations and exclusions.

Utilization management and the authorization program are not the practice of medicine or the provision of medical care to you. Remember, only your doctor can provide you with medical advice and care.

UniCare Member Confidentiality

In order to provide you with health care insurance benefits, UniCare must access certain personal information. UniCare view its duty to maintain the confidentiality of this information as an important responsibility.

To protect the privacy and retain the trust of its members, UniCare provides or obtains personal health information only when it is needed for underwriting, claims adjudication, utilization review, quality management, governmental inquiries, or coordination of benefits.

Your routine consent, provided as part of the enrollment process, or applicable law, allows release of his information for these purposes.

If UniCare receives special requests for an individual's identifiable information for another purpose, including employment, you are given the right to consent or deny the release of this information, except where required by law. You may have access to your medial records. To access records, follow the established procedures of the institution involved. In cases where you are unable to provide consent, your legally designated individual will provide consent and have access to medical records.

In all settings, member information and medical records are protested internally within UniCare's administrative functions.

Plans offered to Illinois-resident individuals are issued under a certificate pursuant to a group policy.

Exclusions and limitations apply to the Plan. Please see the Certificate of Coverage for details.

Sound Plans Limitations & Exclusions The primary limitations and exclusions for these medical insurance plans are listed below. These listings are an overview only. A more detailed list of each plan’s limitations and exclusions can be found in the applicable certificate of coverage. These plans do not provide benefits for: Any amounts in excess of maximum amounts of covered expenses stated in the certificate of coverage Services not specifically listed in the certificate of coverage as covered services Services or supplies that are not medically necessary Services or supplies that UniCare considers to be for experimental procedures or investigative procedures 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 a health policy or insurance coverage 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: (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 participating in the military service of any country; (d) an insured participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured’s commission of, or attempt to commit a felony or as a direct result of the insured being engaged in an illegal occupation; (f) an insured, being under the influence of illegal narcotics, alcohol or non-prescribed controlled substances unless administered under the advice of a physician. Any services provided by a local, state or federal government agency, except when payment under the certificate of coverage is expressly required by federal or state law. If you are eligible for Medicare, any services covered by Medicare under parts A or B are excluded regardless of actual enrollment in Medicare or payment by Medicare for those services. However, for any covered services, if there is a balance remaining after the Medicare payment, or the amount that Medicare would have paid had you enrolled in the program, UniCare will pay the remaining balance up to the Medicare allowable amount. In no event, however, will the actual amount UniCare pay exceed the amount that UniCare would have paid if it were the sole insurance carrier. 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’s home or who is related to the Insured by blood, marriage or adoption, or any of the insured’s employers. 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, or other substance addiction or abuse except as specifically stated in the certificate of coverage. Dental services except as specifically provided in the certificate of coverage. Orthodontic services. Dental implants or associated procedures. Hearing aids. Routine hearing tests except as provided under Well Baby and Well Child Care. Optometric services except as specifically stated in the certificate of coverage. An eye surgery solely for the purpose of correcting refractive defects of the eye. Outpatient speech therapy. Any drugs, medications, or other substances dispensed or administered in any outpatient setting. 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 reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy. 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 except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies. All services related to the evaluation or treatment of fertility and/or infertility. All non-prescription contraceptive drugs, devices and/or supplies that are available over the counter or without a prescription, and non-FDA approved prescription contraceptive drugs, devices and/or supplies. FDA approved prescription contraceptive drugs or devices available through a licensed pharmacy are covered under the prescription drug benefit of this plan. Cryopreservation of sperm or eggs. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics. 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. Charges by a provider for telephone consultations. Items which are furnished primarily for your personal comfort or convenience. Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare. Nutritional counseling or food supplements. Any services received on or within 12 months after the effective date of coverage if they are related to a pre-existing condition. Foreign Country Provider charges are excluded under this Plan except as specifically stated in the certificate of coverage. Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the insured's condition. Routine foot care. Charges for which we are unable to determine our liability because you failed, within 60 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 or other insurance coverage. Charges for animal to human organ transplants. Charges for pregnancy or maternity care, including normal delivery, elective abortions or cesarean sections. Claims received after 15 months from the date the service was rendered.

Medical Underwriting Requirement UniCare believes in fairness, and the cost of covering someone with minimal health care needs should not be unfairly offset by someone whose health can be predicted to require costly care. That's why UniCare offers various levels of coverage, ensuring an overall balance of risk. To determine individual medical risk factors, all enrollments are subject to medical underwriting and approval by UniCare. Depending on the results of underwriting review, a number of things may happen: • you may be offered coverage at the preferred premium charge, or • you may be offered the plan you selected at a higher rate, or • you may not qualify for the plan applied for, but may be offered to apply for an alternative plan, or • you may not qualify for the plan applied for, or an alternative plan, an your application will be rejected. Terms of Coverage Coverage under the health insurance plan will remain in force as long as you pay the required premium. Coverage will cease in the following situations: when the required premiums are not paid on time; when you move out of the state; or in the case of fraud, intentional misrepresentation of materials fact, or if UniCare no longer offers plans of this type or if UniCare ceases offering any individual plans in Illinois to all insureds in your class. Rates Rates are based on the age of the applicant, the residence address and undewriting classification. Rates are recalculated at each billing period based on age and the residence address. Any initial rate guarantees offered under these plans do not include age-banded or area rate changes. UniCare may change the premiums of this plan with 30 days prior written notice to you. However, UniCare will not change rates unless the change applies to all covered persons under the same plan and same class. Emergency If you reasonably believe a medical emergency exist, no utilization or authorization is required. A medical emergency is an unexpected acute illness, injury, or condition that could endanger your health if not treated immediately. Once your condition is stabilized, it is important for the hospital, you, or your family member to contact UniCare for authorization of additional services. 10-Day FREE Look Once your Certificate of Coverage arrives, you have 10 full days to examine and either accept or decline coverage by returning the Certificate of Coverage along with a letter notifying UniCare that you wish to discontinue coverage. Waiting Periods An insured person must be covered for six consecutive months under this plan to be eligible for benefits concerning all services related to: • Hernia except for strangulated or incarcerated hernia • Varicose veins This includes, but is not limited to, all tests, consultations, examinations, medications, and invasive medical laboratory or surgical procedures that are related to the evaluation or treatment of the above items. Pre-Existing Conditions Coverage will not be provided for the 12 months following the effective date of this plan for medical conditions that existed in the 12 months prior to the effective date. Utilization Management and Authorization Program UniCare uses a process called Utilization Management to help you receive coverage for appropriate treatment in the correct setting and helps you avoid both unexpected out-of-pocket costs and unnecessary procedures. Utilization review may take place prior to admission to a hospital or ambulatory surgical center. You must initiate utilization review at least three working days prior to admission. Failure to obtain utilization review prior to services being rendered may result in additional penalties. There are certain other services that require prior authorization to be eligible for maximum benefits. Refer to the Benefits Summary list of specific penalty amounts. Also see your Certificate of Coverage for additional details on preservice review and utilization review, penalties, the authorization program, covered services, and limitations and exclusions. Utilization management and the authorization program are not the practice of medicine or the provision of medical care to you. Remember, only your doctor can provide you with medical advice and care. UniCare Member Confidentiality In order to provide you with health care insurance benefits, UniCare must access certain personal information. UniCare view its duty to maintain the confidentiality of this information as an important responsibility. To protect the privacy and retain the trust of its members, UniCare provides or obtains personal health information only when it is needed for underwriting, claims adjudication, utilization review, quality management, governmental inquiries, or coordination of benefits. Your routine consent, provided as part of the enrollment process, or applicable law, allows release of his information for these purposes. If UniCare receives special requests for an individual's identifiable information for another purpose, including employment, you are given the right to consent or deny the release of this information, except where required by law. You may have access to your medial records. To access records, follow the established procedures of the institution involved. In cases where you are unable to provide consent, your legally designated individual will provide consent and have access to medical records. In all settings, member information and medical records are protested internally within UniCare's administrative functions. Plans offered to Illinois-resident individuals are issued under a certificate pursuant to a group policy. Exclusions and limitations apply to the Plan. Please see the Certificate of Coverage for details.