Medicare Supplement - Extend Health

Live life healthy.Live life secure.Is Original Medicare enough to meet your needs?With Original Medicare you are covered for many hospital and medical expenses,but there are some gaps in that coverage that you may be paying, like deductibles,coinsurance and copays. These costs can add up quickly. For example:• Medicare Part A has an upfront deductible of $1,132* for hospitalization —a deductible you pay before your Medicare coverage begins• If you stay in the hospital more than 60 days, you begin paying a copayof $283* per day• After 90 days in the hospital, your copay increases to $566* per day• You pay 20%* coinsurance for most doctors’ services• You pay 100% for emergency care received outside the U.S., exceptunder limited circumstancesProtect your health with Alliance Medicare Supplement.With Alliance Medicare Supplement, you can fill the coverage gaps and have peaceof mind knowing that you are protected with a plan from Alliance Health and LifeInsurance Company (Alliance). With Alliance Medicare Supplement, you can receivecare anywhere throughout the U.S. that accepts Medicare and, with some plans,you have emergency care throughout the world. Alliance is a wholly owned subsidiaryof Health Alliance Plan (HAP), a Michigan-based company that has been serving thecommunity for more than 50 years.*These are 2011 amounts. 2012 amounts may be higher.Achieving and maintaining good health starts withhealth insurance coverage that fits your personal needsand budget, and a dependable health insurance partnerdedicated to your personal satisfaction.Alliance Medicare Supplementhelps fill the gapsin Original Medicare.3

A plan youcan count on.Freedom and choice.With an Alliance Medicare Supplement plan, you are covered wherever you go.• You can use any doctor, specialist or hospital that participates in Medicare,anywhere in the U.S.• No referrals are necessary or required to see a specialist• Your benefits start on DAY ONE. There is no waiting period for protection to begin*• Worldwide emergency coverage**• And moreSimple and convenient.When you enroll in an Alliance Medicare Supplement plan:• Your health claims are processed quickly by our trained and experienced staff• There is virtually no paperwork for you with our automatic claims processing• Your benefits through Alliance Medicare Supplement change automaticallywhen Original Medicare deductibles, coinsurance or copays change, so youknow you’re covered• Your coverage renews automatically every year as long as you continueto pay your premiumsResponsive customer service.With Alliance, you have the personal service you want from our team of experiencedservice professionals who are located here in Michigan.As an Alliance plan member, you will have a Personal Service Coordinator for thefirst two years — a person you can call directly who can explain plan details, answerquestions and assist you in working through the specifics of your situation.In the years that follow, you can call any of our knowledgeable Customer ServiceRepresentatives whenever you need extra assistance or information. We are alwaysjust a telephone call away.Member-only discounts.As an Alliance Medicare Supplement member, you are eligible to receive discounts,preferred rates and other special savings through an exclusive program we callHAP Advantage. It’s a free program that helps you save money on a variety of thingsyou may need or enjoy, including exercise programs, weight management programs,massage therapy, personal health items and more.A dependable, Michigan-based partner.Medicare beneficiaries in Michigan have relied on us and our Medicare plans for morethan 20 years. By listening carefully to their needs, we have been able to make ourhealth plans and services more responsive to our members. With Alliance, you enjoythe comfort that comes from knowing you have a partner in Michigan that is dedicatedto your satisfaction.*If you delay enrollment and have a health problem that is diagnosed before your Medigappolicy starts, the insurance company can refuse to cover that health problem for up to sixmonths. However, you will still be covered under Original Medicare.**Plan C, Plan F and Plan N.5

Sub1: 24 pt. / 27pt. Your Leading choiceSun of plans. RegularReversed OutWith Alliance Medicare Supplement, you havea choice of plans — Plan A, Plan C, Plan F andPlan N. The benefits of each of these plans arestandardized by the federal government.Plan A provides basic benefits. Plans C, F and Nprovide coverage in addition to the basicbenefits. You choose the plan that best meetsyour needs. (See pages 8 and 9 for moreinformation about each plan.)All four plans offer the basic benefits.The basic benefits include:• Hospitalization: Coverage for Medicare(Part A) daily copays, plus 365 additionaldays (lifetime) after Medicare benefits end• Medical expenses: Coverage for MedicarePart B coinsurance (20% of Medicareapprovedcosts) or copays for doctors’services, hospital outpatient servicesand other medical services• Blood: First three pints of blood each year• Hospice: Coinsurance for inpatient respitecare and copays for hospice outpatientprescription drugsNote: Plans do not include Medicare Part Dprescription drug benefits. For Part D coverage,you might want to consider our AllianceMedicare Rx (pdp) plan.Alliance Medicare SupplementPlan A Plan C Plan F Plan NPlan A is the mostbasic Medigapplan. It helps fillsome of the gaps inMedicare’s coverage.Plan A covers:• Basic benefits(see the listat the left)Plan C provides moreextensive coveragethan Plan A. It maybe the right plan foryou if most of yourdoctors acceptMedicare.Plan C covers:• Basic benefits,plus:• Skilled nursingfacility copay• Part A deductible• Part B deductible• Worldwideemergencycoverage**Plan F may be a goodchoice if some ofyour doctors do notaccept Medicare’sapproved amount aspayment in full.Plan F covers:• Basic benefits,plus:• Skilled nursingfacility copay• Part A deductible• Part B deductible• Worldwideemergencycoverage**• Part B excesscharges (theamount a doctorcharges in excessof the Medicareapprovedamount)Plan N* has a lowmonthly premiumand copays for visitsto the doctor’soffice and theemergency room.Plan N covers:• Basic benefits,plus:• Skilled nursingfacility copay• Part A deductible• Worldwideemergencycoverage***Plan N pays 100% of Part B services except the $162 (in 2011) deductible. Member pays up to $20copay for doctor’s office visits and up to $50 for emergency room visits.**$250 deductible each year. Lifetime maximum of $50,000. Subscriber pays all amounts over $50,000.7

MedicareAlliance MedicareSupplement AAlliance MedicareSupplement CAlliance MedicareSupplement FAlliance MedicareSupplement NWhat benefits aremost importantto you?Medicare Part A Hospital CoverageUpfront deductible($1,132 ‡ per benefit period*)Copay (61-90 days)Medicare PaysNothingAll but $283 ‡ a dayPlanPaysSubscriberPaysPlanPaysSubscriberPaysPlanPaysSubscriberPaysPlanPaysSubscriberPaysNothing $1,132 ‡ $1,132 ‡ Nothing $1,132 ‡ Nothing $1,132 ‡ Nothing$283 ‡ a day Nothing $283 ‡ a day Nothing $283 ‡ a day Nothing $283 ‡ a day NothingAlliance Medicare Supplement plan isnot connected with or endorsed by theUnited States Government or the FederalMedicare program. Neither Alliance MedicareSupplement nor its agents are connectedwith Medicare.Copay (91-150 days)Extended hospital coverage(up to an additional 365 days inyour lifetime)Benefit for bloodin total out-of-pocket costsSkilled Nursing Facility**All but $566 ‡ a dayNothingAll but first 3 pints$566 ‡ a day Nothing $566 ‡ a day Nothing $566 ‡ a day Nothing $566 ‡ a day Nothing100% ofMedicareeligibleexpensesNothing100% ofMedicareeligibleexpensesNothing100% ofMedicareeligibleexpensesNothing100% ofMedicareeligibleexpensesNothing3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints NothingThis outline of coverage does not give all thedetails of Medicare coverage.This policy may not fully cover all of yourmedical costs.Contact your local Social Security officeor consult the booklet “Medicare and You”for more details.*A benefit period begins the day you go into thehospital and ends when you have been out ofthe hospital for 60 days in a row. If you go intothe hospital again after 60 days have passed, youbegin a new benefit period.**You must meet Medicare’s requirements, includinghaving been in a hospital for at least three days,and enter a Medicare-approved facility within 30days after leaving the hospital.†Subscriber pays all amounts over $50,000.‡These are 2011 amounts. 2012 amounts maybe higher.First 20 days 100%Coinsurance 21-100 daysAll but$141.50 ‡ a dayMedicare Part B Physician’s Services and SuppliesUpfront deductible($162 ‡ per year)Coinsurance/copayExcess benefits(the amount a doctor chargesin excess of the Medicareapprovedamount)Benefit for bloodin total out-of-pocket costsAdditional BenefitsEmergency care receivedoutside of the U.S.Nothing80%NothingAll but first 3 pintsNothing(except underlimitedcircumstances)Nothing Nothing Nothing Nothing Nothing Nothing Nothing NothingNothingUp to$141.50 ‡a dayUp to$141.50 ‡a dayNothingUp to$141.50 ‡a dayNothingUp to$141.50 ‡a dayNothingNothing $162 ‡ $162 ‡ Nothing $162 ‡ Nothing Nothing $162 ‡20% Nothing 20% Nothing 20% Nothing 20%NothingAll costsup to 15%aboveMedicareapprovedamountNothingAll costsup to 15%aboveMedicareapprovedamountAll costsup to 15%aboveMedicareapprovedamountNothingNothing$20 MD/$50 ERAll costsup to 15%aboveMedicareapprovedamount3 pints Nothing 3 pints Nothing 3 pints Nothing 3 pints NothingNothingAll80% toa lifetimemaximumof $50,000†$250deductible.20% toa lifetimemaximumof $50,000†80% toa lifetimemaximumof $50,000†$250deductible.20% toa lifetimemaximumof $50,000†80% toa lifetimemaximumof $50,000†$250deductible.20% toa lifetimemaximumof $50,000†9

What you needto know aboutAlliance MedicareSupplement plans.Policy replacement.If you are replacing another health insurancepolicy, do not cancel it until you have actuallyreceived your new policy and are sure youwant to keep it.Disclosure.Use this outline to compare benefits andpremiums among policies, certificatesand contracts.Please read your policy very carefully.This is only an outline describing your policy’smost important features. The policy is yourinsurance contract. You must read the policyitself to understand all of the rights and dutiesof both you and your insurance company.Right to return policy.If you find that you are not satisfied withyour policy, you may return it to:HAP Medicare Division2850 W. Grand BoulevardDetroit, MI 48202If you send the policy back to us within 30 daysafter you receive it, we will treat the policyas if it had never been issued and return allof your payments.Notice.This policy may not fully cover all of yourmedical costs. Neither Alliance MedicareSupplement nor its agents are connectedwith Medicare and are not connected withor endorsed by the United States Governmentor the Federal Medicare program. This outlineof coverage does not give all the detailsof Medicare coverage. Contact your localSocial Security office or consult the booklet“Medicare and You” for more details.Complete answers are very important.When you fill out the application for the newpolicy, be sure to answer, truthfully andcompletely, all questions about your medicaland health history. Alliance may cancel yourpolicy and refuse to pay any claims if you leaveout or falsify important medical information.Review the application carefully before yousign it. Be certain that all information hasbeen properly recorded.Premium information.Please refer to the following charts (Non-Smoker and Smoker) to determine your specificAlliance Medicare Supplement plan premium effective January 1, 2012.Plan ANon-SmokerPlan CNon-SmokerPlan FNon-SmokerPlan NNon-SmokerAge Male Female Male Female Male Female Male Female65-69 $131 $131 $148 $148 $176 $174 $121 $12170-74 $165 $150 $191 $174 $228 $206 $157 $14275-79 $188 $164 $225 $199 $268 $237 $184 $16380-84 $199 $166 $252 $215 $300 $257 $206 $17785+ $207 $179 $267 $228 $323 $271 $219 $187Plan ASmokerPlan CSmokerPlan FSmokerPlan NSmokerAge Male Female Male Female Male Female Male Female65-69 $144 $144 $163 $163 $194 $191 $133 $13370-74 $182 $165 $210 $191 $251 $227 $173 $15675-79 $207 $180 $248 $219 $295 $261 $202 $17980-84 $219 $183 $277 $237 $330 $283 $227 $19585+ $228 $197 $294 $251 $355 $298 $241 $2062012 rates are pending state approval.Medicare beneficiaries younger than age 65 are only eligible to apply for Plan A or Plan C. Monthlypremiums would be the same as the premiums for ages 85+.Alliance Health and Life Insurance Company can raise your premium only if we raise the premium forall policies like yours in Michigan (subject to state approval). Rates may change annually. You maykeep your plan active by paying the required monthly premium amount when due.11

More informationabout AllianceMedicareSupplement.How do I know if I am eligible for Alliance Medicare Supplement?Generally, if you are a Michigan resident enrolled in both Medicare Parts A and B,you are eligible for Alliance Medicare Supplement. You will have to continue to paythe monthly Medicare Part B premium. In addition, you will have to pay a premiumfor your Alliance Medicare Supplement policy.When can I sign up for Alliance Medicare Supplement?You can purchase Alliance Medicare Supplement at any time. The best time to purchaseyour policy is when you become eligible for Medicare and enroll in Medicare Part B.Am I covered when I travel?Yes. Your coverage goes with you anywhere in the United States. With Plan C, Plan Fand Plan N, you also have worldwide emergency coverage, with limitations.In some cases, if you have a health problem that is diagnosed before your MedicareSupplement policy starts, the insurance company can refuse to cover that healthproblem for up to six months. This is called a “pre-existing condition waiting period.”The insurance company can only use this kind of waiting period if your health problemwas diagnosed or treated during the six months before the policy started. If you buy aMedigap policy when you have special Medigap protections or guaranteed issue rights,you will not be subject to a pre-existing condition waiting period.Once you are enrolled in a Medicare Supplement plan, your coverage will continueto be renewed as long as you pay the premium.Can I keep my Alliance Medicare Supplement policy if I move out-of-state?Yes. You can keep your current Medicare Supplement policy regardless of where you liveas long as you are still in the Original Medicare plan and maintain your Part B coverage.How can I get prescription drug coverage?If you are interested in Medicare prescription drug benefits in addition to yourAlliance Medicare Supplement plan, we invite you to consider our Alliance Medicare Rxprogram. Alliance Medicare Rx (pdp) is a stand-alone Prescription Drug Plan with aMedicare contract. Just give us a call, and we will be happy to discuss your options andsend you a free information package.Do I need a referral to see a specialist?No. Referrals are not required. You can see any doctor or specialist who participatesin Medicare.Can my coverage be denied?When you turn 65, participate in Medicare Part A and enroll in Medicare Part B, youhave a guaranteed right to buy an Alliance Medicare Supplement plan for six months.You cannot be refused if you sign up during this open enrollment period.If you try to enroll in a Medicare Supplement after your first six months of eligibility,an insurance company can refuse to sell you a policy or charge you higher premiumsbased on certain health conditions.13

Call today.To enroll in Alliance Medicare Supplement, you can use one of thefollowing options:1. Mail a completed application form to:HAP Medicare Division2850 W. Grand BoulevardDetroit, Michigan 48202If you need an application form, please call us toll-free at (800) 868-3153 orTTY/TDD (800) 649-3777, Monday through Friday, 8 a.m. to 5 p.m.2. Visit us at www.hap.org/medicare. The application form is available online for youto download, complete and mail to us.3. Come to a HAP Medicare workshop where you can talk with other Medicarebeneficiaries. We hold workshops in Wayne, Oakland, Macomb, Genesee, Lapeer,Livingston, Monroe, St. Clair and Washtenaw counties.A licensed, Michigan-based Alliance Medicare Sales Person will be present withinformation and applications to assist you. Call us toll-free for dates and locationsor for accommodation of persons with special needs at sales meetings: (800) 449-1515or TTY/TDD (800) 649-3777, Monday through Friday, 8 a.m. to 6 p.m. ETIf you have questions, or if you are looking for more informationabout our benefits or enrollment periods, just call a licensed,Michigan-based Alliance Medicare Sales Representative toll-free at:(800) 868-3153 or TTY/TDD (800) 649-3777.Alliance Medicare Rx (pdp) members who want to learn more about Alliance MedicareSupplement can call us toll-free at the numbers above.For your convenience, our office hours are:October 15 through February 148 a.m. to 8 p.m., seven days a weekFebruary 15 through October 148 a.m. to 8 p.m., Monday through Friday8 a.m. to noon, SaturdayOutside of those business hours, you may access our Interactive Voice Recording systemat the same number and leave your name and phone number. An Alliance MedicareCustomer Service Representative will return your phone call the next business day.You can also mail your questions to:HAP Client ServicesAttn: Medicare2850 W. Grand BoulevardDetroit, Michigan 48202Or visit us on the web at:www.hap.org/medicare.15

Value. Choice. Experience.Count on it.Prospective members: If you have questions, or if you are looking for more informationabout our benefits or enrollment periods, call a licensed, Michigan-basedAlliance Medicare Sales Representative toll-free at:(800) 868-3153 or TTY/TDD (800) 649-3777For your convenience, our office hours are:October 15 through February 14 8 a.m. to 8 p.m., seven days a weekFebruary 15 through October 148 a.m. to 8 p.m., Monday through Friday8 a.m. to noon, SaturdayOutside of those business hours, you may access our Interactive Voice Recordingsystem at the same number and leave your name and phone number. An Alliance MedicareCustomer Service Representative will return your phone call the next business day.www.hap.org/medicareImproving health. Enhancing lives.2011 Health Alliance Plan of Michigan. A Nonprofit Company504998_55p09.2011