How a full-suite Critical Illness plan worked for a couple over 65

Frank and Carol have been married for 41 years. They live in a single-story house in Las Vegas that they paid off two years ago. Frank is a retired bus mechanic. Carol worked as a school secretary until she retired.

They both have Medicare, through a Medicare Advantage plan with another company. It covers their doctor visits and hospital care, with copays along the way. They budget carefully on their pensions and Social Security.

When Frank was 68 and Carol was 66, they started asking a question many couples their age ask. If one of them had a serious illness, what would it cost beyond what Medicare covers? Help around the house, changes to the home, rides, time. None of that is on a medical bill.

Why they chose the full suite

They looked at CriticalGuard, a critical illness plan underwritten and administered by Golden Rule Insurance Company, a UnitedHealthcare company. It comes in four plans:

• Cancer
• Heart/Stroke
• Cancer + Heart/Stroke
• Critical Illness, the full suite

The full-suite Critical Illness plan covers three categories of Qualifying Events:

• Cancer: life-threatening cancer (100%), cancer in situ (25%), benign brain tumor (25%) and skin cancer ($500).
• Heart/Stroke: heart attack (100%), stroke (100%) and heart illness (25%).
• Critical Conditions: Advanced Alzheimer’s Disease, ALS, coma lasting at least 7 consecutive days, end stage renal failure and major organ transplant (each 100%), and loss of independent living (50%).

Frank and Carol chose the full suite. At their age, the Critical Conditions category mattered to them as much as cancer or heart disease. The thought of one of them no longer being able to live independently was the thing they talked about most.

The plan covers Frank as the primary insured and Carol as his spouse. The brochure says benefits are per covered person.

Choosing the amount, and what guaranteed issue means

Next they chose a Benefit Lifetime Maximum Amount. It’s the most the plan will pay in a lifetime for one category. You choose it in $5,000 steps, and the range depends on the age at issue:

• Ages 65 to 74: $5,000 to $75,000
• Ages 75 to 90: $5,000 to $50,000

Buying in their late 60s meant a higher ceiling was open to them than if they had waited until 75.

At issue ages 65 to 74, a maximum of $5,000 is guaranteed issue. That means no underwriting and no medical questions. Above that, plans are simplified issue, which means some medical questions. The brochure says this depends on the primary insured’s issue age and the benefits chosen.

Guaranteed issue is a real option. It’s worth knowing what it does and doesn’t do:

• It does let you get coverage without answering medical questions.
• It doesn’t remove the preexisting conditions limitation. The brochure says all plans are subject to it.
• It doesn’t change the percentages. A stroke on a $5,000 plan pays 100% of $5,000, which is $5,000.

Frank and Carol wanted more than $5,000. They chose $25,000, answered the medical questions carefully, and were approved. The brochure warns that incorrect or incomplete answers can void coverage or lead to denied claims.

Here is what $25,000 meant in practice. Because the full suite has three categories, and each has its own maximum, each of them had up to:

• $25,000 for Cancer
• $25,000 for Heart/Stroke
• $25,000 for Critical Conditions

That’s up to $75,000 across the three categories for each of them, according to the policy’s terms. A claim in one category doesn’t reduce the others.

The extras

Every CriticalGuard plan includes a COVID benefit of $10,000. It pays for confinement to an intensive care unit with a positive COVID diagnosis at the same time. It’s limited to one benefit per person per lifetime, and it doesn’t count against the Benefit Lifetime Maximum Amount.

They also added the Wellness rider. It pays $75 per exam for a covered wellness exam or procedure, such as an annual physical or immunization, limited to one exam per calendar year. Rider benefits are per person, so with both of them on the policy, that was up to $150 a year between them. Like all riders, it cost extra and could only be added when they applied. It has the same 30-day waiting period as the plan.

What happened

Three years after the plan took effect, Carol was 69. One morning at breakfast, Frank noticed she couldn’t lift her coffee cup with her right hand, and her words came out wrong. He called for an ambulance. At the hospital, doctors confirmed she’d had a stroke.

Carol spent a week in the hospital and then several weeks in rehabilitation. Their Medicare Advantage plan covered her care, with the copays and limits of that plan.

How the claim worked

The brochure asks for notice of a claim within 30 days after the First Diagnosis, or as soon as reasonably possible. Frank printed the claim form from the UHC Member Hub the week Carol came home from the hospital. He sent it in with the information the form asked for.

Stroke is a Heart/Stroke Qualifying Event that pays 100%:

• Carol’s Heart/Stroke Benefit Lifetime Maximum Amount: $25,000
• Share for a stroke: 100%
• $25,000 × 100% = $25,000

The plan paid $25,000 in one lump sum, directly to them. It paid regardless of their Medicare Advantage coverage. The brochure says benefits are a stated amount, regardless of the actual expense.

After the claim, this is where their coverage stood:

• Carol, Heart/Stroke: $25,000 paid, $0 left
• Carol, Cancer: $25,000 still available
• Carol, Critical Conditions: $25,000 still available
• Frank: all three categories untouched, up to $25,000 each

Where the money went

The money was theirs to use however they chose. They spent it on the things Medicare doesn’t pay for:

• $9,000 to make the house safer: grab bars, a walk-in shower and a ramp at the back door.
• $6,000 for an aide a few hours a week for four months, so Frank could rest and run errands.
• $2,400 for copays on Carol’s outpatient therapy under their Medicare Advantage plan.
• $600 for gas, parking and meals during the hospital weeks.
• $7,000 kept in savings.

That adds up to $25,000. It meant they didn’t have to sell Frank’s truck or ask their kids for money.

The support programs

The full-suite plan also includes three Optum programs at no added cost for the people on the policy. The brochure is clear that these programs are not insurance, and they may require a diagnosis to qualify.

• Optum Perks is a prescription discount card. It’s a discount program, open to the general public. You show the card at the pharmacy.
• The Optum Heart Failure and Coronary Artery Disease Management Program offers information and resources to help someone understand a heart condition, manage symptoms through daily monitoring, and stick to a doctor’s treatment plan and medication.
• The Optum Cancer Resource Service offers an oncology nurse, guidance to providers for treatment or a second opinion, and information on clinical trials and community resources.

Carol didn’t need the heart or cancer programs. But she and Frank both started using the Optum Perks card for their regular prescriptions. Knowing the other two programs were there, if either of them ever needed one, was part of why they chose the full suite.

Loss of independent living: the 50% benefit

Carol worked hard in therapy and got back most of what she’d lost. But her stroke made them think about the benefit they’d cared about most when they bought the plan: loss of independent living.

According to the brochure, it pays 50% of the Critical Conditions maximum. It’s for the permanent inability to perform 2 or more of the 6 activities of daily living, as the policy defines them, for a period of at least 90 days. The brochure’s examples include bathing, dressing, eating and toileting. It’s limited to one benefit per person, per lifetime.

On a $25,000 plan, the arithmetic would be:

• $25,000 × 50% = $12,500 paid
• $25,000 − $12,500 = $12,500 still available in the Critical Conditions category

The brochure says the remaining amount stays available for a later Critical Conditions Qualifying Event, according to the policy’s terms, up to the maximum.

One honest note. The policy excludes loss from other illnesses, including illness that may have been complicated or caused by a Qualifying Event. If you’re thinking about how one condition might lead to another, read the policy wording closely, or ask before you buy, rather than assume.

What the plan didn’t do

It didn’t pay twice for heart and stroke. Carol’s Heart/Stroke category is now paid in full. If she has a heart attack later, this plan won’t pay another Heart/Stroke benefit for her.

It pays on First Diagnosis only. In most states, the plan pays for the first occurrence of a Qualifying Event in your lifetime. A stroke or cancer diagnosed before you bought the plan wouldn’t count, and neither would any diagnosis made before your effective date.

It has a waiting period and a preexisting conditions limitation. Every plan has a 30-day waiting period after the effective date. The policy also won’t pay for a Qualifying Event caused or contributed to by a Preexisting Condition. That includes a condition you had care, treatment or advice for in the 12 months before your effective date. This limitation lasts no longer than 12 months after the effective date. Carol’s stroke came three years in. Some states define these terms differently.

It’s not Medicare, and it doesn’t replace Medicare. The brochure’s notice says the plan is separate from any health insurance or Medicare Advantage coverage you buy from another company. It isn’t required to buy health insurance. It shouldn’t be used as a substitute for comprehensive coverage, and it isn’t Minimum Essential Coverage.

There are other exclusions. Among them: a diagnosis made outside the United States, a diagnosis made by a member of your immediate family or household, and, on the full-suite plan, an intentionally medically induced Critical Condition, except for a major organ transplant.

What Medicare-age readers should know

If you’re over 65 and thinking about a plan like this:

• It sits beside your Medicare coverage, not inside it. Your Medicare or Medicare Advantage plan still pays your medical bills under its own rules. CriticalGuard pays you a lump sum on a covered diagnosis.
• Your age at purchase sets your range. From 65 to 74 you can choose up to $75,000. From 75 to 90, up to $50,000.
• Guaranteed issue is $5,000 at these ages. It’s the simplest path in, but think about whether $5,000 per category would cover what you’re planning for.
• It’s guaranteed renewable for life, as outlined in the policy. It renews until the maximums are paid, premiums go unpaid, you ask to end it, or there is fraud. Premiums can change, but not solely because you made a claim or your health changed. In Nevada, the brochure lists at least 60 days’ notice of any premium change.
• You have a free look. After the policy arrives, you can return it within 10 days, or longer in some states, for a refund of the premium you paid.

Questions worth asking before you apply:

1. What would we spend money on if one of us became seriously ill, beyond what Medicare pays?
2. Is the full suite worth it to us, or is a single category enough?
3. Is $5,000 guaranteed issue enough, or do we want a higher amount with medical questions?
4. Does anything in our last 12 months of care count as a Preexisting Condition?
5. Do we want a rider? We can only add one when we apply.

This is a fictional illustration. Actual policy benefits, underwriting rules, and availability depend on carrier guidelines and state regulations.