Harken Health – Care Gold PPO Plans
Harken Health is a new health insurance company offered in Illinois. It is partially owned by United Healthcare but is has an new approach to health insurance and considered a completely separate company in both plan designs and networks than United HealthOne. Harken Health is offering 4 PPO plans in 2016 to the Individual Market to Illinois residents ONLY living in Cook County.
Key features to all Harken Health Plans include:
- Large PPO Hospital Network
- They will be the only individual PPO plans that will include Rush University Hospital in-network in 2016
- Plans includes a nationwide network of approximately 850,000 physicians, hospitals and care facilities
- All plans include unlimited, no charge health visits at Harken Health Centers
- 24 hour, 7 days a week access to Harken Health doctors
- Prescription drug coverage and online ordering
- Mental health care and wellness classes
Harken Gold Plans
Our Rating: 
There are 2 Harken Health Gold Plan Options:
- Care Gold Plan I – $1,750 individual deductible / $3,500 family deductible and 100% coinsurance after deductible
- Care Gold Plan II – $1,375 individual deductible / $2,750 family deductible and 100% coinsurance after deductible
Key Harken Health Gold Plan features include:
- unlimited, no charge health visits at Harken Health Centers
- Prescription drug coverage – including $5 generic copays
- No referrals to see a specialist
- Offered both on-exchange and off-exchange
- Maternity Coverage
- Well-adult care covered at 100%
- Well-child care covered at 100%
- Diagnostic testing
- Hospital services
- Access to the UHC Choice Plus national PPO network, which includes coverage while traveling out of state coverage
| Harken Health Gold Deductibles | |
|---|---|
| $1,750 single / $3,500 family | |
| $1,375 single / $2,750 family | |
Care Gold I
|
Important Questions |
Answers |
Why this Matters: |
|
What is the overall deductible? |
Designated network: $1,750 person / |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. |
|
Are there other deductibles for specific services? |
No. There are no other specific deductibles. |
You don’t have to meet deductiblesfor specific services, but see the chart starting on page 2 for other costs for services this plan covers. |
|
Is there an out–of–pocket limit on my expenses? |
Yes. Designated network & Network: |
The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. |
|
What is not included in the out–of–pocket limit? |
Penalties for failure to obtain prior authorization, premiums, balance-billed charges, and health care this plan does not cover. |
Even though you pay these expenses, they don’t count toward the out-ofpocket limit on your expenses. |
|
Is there an overall annual limit on what the plan pays? |
No. |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
|
Does this plan use a network of providers? |
Yes. See: |
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network providerfor some services. Plans use the term in-network, preferred, or participating for providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. |
|
Do I need a referral to see a specialist? |
No, you don’t need a referral to see a specialist. |
You can see the specialist you choose without permission from this plan. |
|
Are there services this plan doesn’t cover? |
Yes. |
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. |
|
Common |
Services You May Need |
Your Cost If You Use a |
Your Cost If |
Your Cost If |
Limitations & Exceptions |
|
If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
No charge |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
Specialist visit |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
Other practitioner office visit |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Per person per calendar year visits limited for manipulative treatment- 16. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Preventive care/screening/ immunization |
No charge |
No charge |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
If you have a test |
Diagnostic test (xray, blood work) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Imaging (CT/PET scans, MRIs) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If you need drugs to treat your illness or |
Tier 1 |
Retail: $5/ prescription Mail Order: $10/ prescription |
Retail: $5/ prescription Mail Order: $10/ prescription |
20% coinsurance after deductible |
Limited to a 31 day supply per prescription or refill. Mail order limited to 90 day supply. Certain drugs may have a pre-authorization requirement. |
|
Tier 2 |
Retail: $35/ prescription Mail Order: $70/ prescription |
Retail: $35/ prescription Mail Order: $70/ prescription |
20% coinsurance after deductible |
||
|
Tier 3 |
Retail: $200/ prescription Mail Order: $400/ prescription |
Retail: $200/ prescription Mail Order: $400/ prescription |
20% coinsurance after deductible |
||
|
Tier 4 |
Retail: $350/ prescription Mail Order: $700/ prescription |
Retail: $350/ prescription Mail Order: $700/ prescription |
20% coinsurance after deductible |
||
|
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Physician/surgeon fees |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If you need immediate medical attention |
Emergency room |
No charge after deductible |
No charge after deductible |
No charge after deductible |
–––––––––––none––––––––––– |
|
Emergency medical transportation |
No charge after deductible |
No charge after deductible |
No charge after deductible |
–––––––––––none––––––––––– |
|
|
Urgent care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
If you have a hospital stay |
Facility fee (e.g., hospital room) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Physician/surgeon fee |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
No charge |
No charge |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Mental/Behavioral health inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
Substance use disorder |
No charge |
No charge |
20% coinsurance after deductible |
||
|
Substance use disorder inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
If you are pregnant |
Prenatal and postnatal care |
No charge |
No charge |
20% coinsurance after deductible |
Certain postnatal services are subject to deductible and coinsurance. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Delivery and all inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
If you need help recovering or have other special health needs |
Home health care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Rehabilitation services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Per person per calendar year visits are limited for pulmonary and cognitive therapy – 20 each; cardiac therapy – 72; and post-cochlear therapy – 30. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Habilitative services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Skilled nursing care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
|
Durable medical equipment |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network for equipment that exceeds $1,000 in cost or benefits are reduced by the lesser of 50% or $1,000. |
|
Hospice service |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If your child needs dental or eye care |
Eye exam |
No charge |
No charge |
20% coinsurance after deductible |
Limited to 1 exam every 12 months. |
|
Glasses |
No charge |
No charge |
20% coinsurance after deductible |
Limited to 1 pair every 12 months. |
|
|
Dental check-up |
No charge |
No charge |
20% coinsurance |
Oral evaluations and cleanings are covered 2 times per 12 months. |
Excluded Services & Other Covered Services:
| Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
|
| Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
|
Care Gold II
|
Important Questions |
Answers |
Why this Matters: |
|
What is the overall deductible? |
Designated network: $1,375 person / |
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. |
|
Are there other deductibles for specific services? |
No. There are no other specific deductibles. |
You don’t have to meet deductiblesfor specific services, but see the chart starting on page 2 for other costs for services this plan covers. |
|
Is there an out–of–pocket limit on my expenses? |
Yes. Designated network & Network: |
The out-of-pocket limitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. |
|
What is not included in the out–of–pocket limit? |
Penalties for failure to obtain prior authorization, premiums, balance-billed charges, and health care this plan does not cover. |
Even though you pay these expenses, they don’t count toward the out-ofpocket limit on your expenses. |
|
Is there an overall annual limit on what the plan pays? |
No. |
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. |
|
Does this plan use a network of providers? |
Yes. See: |
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network providerfor some services. Plans use the term in-network, preferred, or participating for providersin their network. See the chart starting on page 2 for how this plan pays different kinds of providers. |
|
Do I need a referral to see a specialist? |
No, you don’t need a referral to see a specialist. |
You can see the specialist you choose without permission from this plan. |
|
Are there services this plan doesn’t cover? |
Yes. |
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services. |
|
Common |
Services You May Need |
Your Cost If You |
Your Cost If |
Your Cost If |
Limitations & Exceptions |
|
If you visit a health care provider’s office or clinic |
Primary care visit to treat an injury or illness |
No charge |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
Specialist visit |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
Other practitioner office visit |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Per person per calendar year visits limited for chiropractic care – 16. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Preventive care/screening/ immunization |
No charge |
No charge |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
If you have a test |
Diagnostic test (xray, blood work) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
Imaging (CT/PET scans, MRIs) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If you need drugs to treat your illness or |
Tier 1 |
Retail: $5/ prescription Mail Order: $10/ prescription |
Retail: $5/ prescription Mail Order: $10/ prescription |
20% coinsurance after deductible |
Limited to a 31 day supply per prescription or refill. Mail order limited to 90 day supply. Certain drugs may have a pre-authorization requirement. |
|
Tier 2 |
Retail: $35/ prescription Mail Order: $70/ prescription |
Retail: $35/ prescription Mail Order: $70/ prescription |
20% coinsurance after deductible |
||
|
Tier 3 |
Retail: $200/ prescription Mail Order: $400/ prescription |
Retail: $200/ prescription Mail Order: $400/ prescription |
20% coinsurance after deductible |
||
|
Tier 4 |
Retail: $350/ prescription Mail Order: $700/ prescription |
Retail: $350/ prescription Mail Order: $700/ prescription |
20% coinsurance after deductible |
||
|
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Physician/surgeon fees |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Certain procedures require prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If you need immediate medical attention |
Emergency room |
No charge after deductible |
No charge after deductible |
No charge after deductible |
–––––––––––none––––––––––– |
|
Emergency medical transportation |
No charge after deductible |
No charge after deductible |
No charge after deductible |
–––––––––––none––––––––––– |
|
|
Urgent care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
–––––––––––none––––––––––– |
|
|
If you have a hospital stay |
Facility fee (e.g., hospital room) |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Physician/surgeon fee |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
If you have mental health, behavioral health, or substance abuse needs |
Mental/Behavioral health outpatient services |
No charge |
No charge |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
Mental/Behavioral health inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
Substance use disorder |
No charge |
No charge |
20% coinsurance after deductible |
||
|
Substance use disorder inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
If you are pregnant |
Prenatal and postnatal care |
No charge |
No charge |
20% coinsurance after deductible |
Certain postnatal services are subject to deductible and coinsurance. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
Delivery and all inpatient services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
||
|
If you need help recovering or have other special health needs |
Home health care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
Rehabilitation services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
Per person per calendar year visits are limited for pulmonary and cognitive therapy – 20 each; cardiac therapy – 72; and post-cochlear therapy – 30. You must obtain prior authorization for non-network or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Habilitative services |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
Skilled nursing care |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
|
Durable medical equipment |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork for equipment that exceeds $1,000 in cost or benefits are reduced by the lesser of 50% or $1,000. |
|
Hospice service |
No charge after deductible |
No charge after deductible |
20% coinsurance after deductible |
You must obtain prior authorization for nonnetwork or benefits will be reduced by the lesser of 50% or $1,000. |
|
|
If your child needs dental or eye care |
Eye exam |
No charge |
No charge |
20% coinsurance after deductible |
Limited to 1 exam every 12 months. |
|
Glasses |
No charge |
No charge |
20% coinsurance after deductible |
Limited to 1 pair every 12 months. |
|
|
Dental check-up |
No charge |
No charge |
20% coinsurance |
Oral evaluations and cleanings are covered 2 times per 12 months. |
Excluded Services & Other Covered Services:
| Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) |
|
| Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.) |
|
