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Gold 80 HMO
Plan Summary
Plan Type
Office Visit for Primary Doctor
Find Doctors 		N/A
Office Visit for Specialist N/A
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible None
Separate Prescription Drugs Deductible N/A
Coinsurance N/A
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit $0
Lifetime Maximum N/A
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage  
Office Visit
Primary Care Physician Required N/A
Specialist Referrals Required N/A
Preventive Care Coverage
Periodic Health Exam N/A
Periodic OB-GYN Exam N/A
Well Baby Care N/A
Emergency and Urgent Care
Emergency Room N/A
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible N/A
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery N/A
Outpatient Lab/X-Ray N/A
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization N/A
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit N/A
Labor & Delivery Hospital Stay N/A
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage N/A
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating A as of 08/14/2024
Electronic Signature for Application Available No
Details and documents about this plan
View Plan Brochure (Not available)

The carrier has not provided a separate document for Exclusions and Limitations.

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • Golden Rule - These plans are available only to members of the Federation of American Consumers and Travelers (FACT), an independent consumer organization. If you are not already a member of FACT, you must join in order to be eligible for these plans. Through a special agreement between FACT and Golden Rule Insurance Company, you can enroll in the association on this web site. You will fill out the FACT enrollment form prior to making application to Golden Rule for health insurance. For more information on the benefits of FACT membership, visit http://usafact.org/. Estimated Monthly Cost includes the mandatory $3 per month dues for FACT membership. FACT membership is not required in all states; refer to the product brochure for more information.
  • Golden Rule - Policy form numbers (renewable plans): C-006.3 or C-006.4 or state variations; GRI-PA-20.1-06 or -21.1-06 (CT); GRI-N21M or GRI-N21S-07 (DE); GRI-PA-22.1-10 or -23.1-10 (GA); UHC06-N21M-17 or UHC06-N21S-17 (LA); GRI-N21M-15 or GRI-N21S-15 (KS); GRI-N22M-16 or GRI-N22S-16 (KY); GRI-N21M-30 or GRI-N21S-30 (NM); GRI-N21M-40 or GRI-N21S-40 (SD); MGR03928 (TX); and GRI-N22M-49 or GRI-N22S-49 (WY). Policy form numbers (Short Term Medical): GRI-H-5.7 or state variations, UHC-H-5.7 (LA); and MGR03927 (TX). In LA, plans are offered by United Healthcare Insurance Company and administered by Golden Rule. Be sure to download the brochure before you apply. It contains important information regarding benefits, exclusions, limitations, renewability, eligibility, and other terms of coverage.