Outline of Medicare Supplement Coverage

Outline of Medicare

Supplement Coverage

Premium information

Health Alliance Medical Plans, Inc., can only raise your premium if we raise the premium for all policies like yours in this state. We will not change your premium or cancel your policy because of poor health. If your premium changes, you will be notified at least 30 days in advance.

Disclosures

Use this outline to compare benefits and premiums among policies.

This outline shows benefits and premiums of policies sold for effective dates on or after June 1, 2010.

reaD your Policy very carefully

This is only an outline, describing each policy’s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Health Alliance Medical Plans, Inc.

right to return Policy

If you find that you are not satisfied with your policy, you may return it to Health Alliance Medical Plans, Inc., Attn: Medicare Department, 301 S. Vine St., Urbana, IL 61801-3347. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments.

Policy rePlacement

If you are replacing another health insurance policy, DO NOT cancel it until you have actually received your new policy and are sure you want to keep it.

notice

This policy may not fully cover all of your medical costs. Neither Health Alliance Medical Plans, Inc., nor its agents are connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social

Security office or consult Medicare & You for more

details.

monthly Premium rates

northern/central anD southern illinois

Rates shown are for Illinois residents living

outside of Cook, DuPage, Kane, Lake, McHenry and Will counties. If you are an Illinois resident living in one of these counties, please call our toll-free number for the appropriate rates.

New rates will go into effect March 1.

ages Plan a Plan c Plan f Plan n

65 $100.26 $163.63 $167.23 $109.44

66 $105.27 $171.81 $175.59 $114.92

67 $110.53 $180.40 $184.37 $120.66

68 $116.06 $189.42 $193.59 $126.70

69 $121.86 $198.89 $203.27 $133.03

70 $127.95 $208.83 $213.43 $139.68

71 $134.35 $219.28 $224.10 $146.67

72 $141.07 $230.24 $235.31 $154.00

73 $148.12 $241.75 $247.07 $161.70

74 $155.53 $253.84 $259.43 $169.78

75 $163.31 $266.53 $272.40 $178.27

76 $171.47 $279.86 $286.02 $187.19

77 $176.62 $293.85 $300.32 $196.55

78 $178.17 $308.54 $315.33 $206.37

79 $179.77 $319.30 $326.33 $213.57

80 $181.42 $328.22 $335.45 $219.54

81 $183.12 $337.94 $345.39 $226.05

82 $184.88 $348.56 $356.25 $233.15

83 $184.88 $353.45 $361.25 $236.42

84 $184.88 $358.81 $366.72 $240.00

85+ $184.88 $364.66 $372.70 $243.92

<65 $184.88 $364.66 $372.70 $243.92

comPlete ansWers are very imPortant

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

outline of medicare supplement coverage

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A available. Some plans may not be available in Illinois.

a B c D f/f* G K** L*** M n

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Hospitalization and Preventive Care paid at 100%; other Basic Benefits paid at 50%

Hospitalization and Preventive Care paid at 100%; other Basic Benefits paid at 75%

Basic Benefits including 100% Part B coinsurance

Basic Benefits

including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance

50% Skilled Nursing

Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance

Part A Deductible Part a _Deductible Part A Deductible Part a _Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part a Deductible

Part B

Deductible Part B Deductible

Part B Excess

(100%) Part B Excess (100%)

foreign travel

Emergency Foreign Travel Emergency

foreign travel Emergency

Foreign Travel

Emergency Foreign Travel Emergency foreign travel Emergency

100% after $4,940 Out-of-pocket Annual Limit

100% after $2,470 Out-of-pocket Annual Limit

*NOTE: Plan f also has an option called a high-deductible Plan F. This high deductible plan pays the same

benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

outline of medicare supplement coverage

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A available. Some plans may not be available in Illinois.

a B c D f/f* G K** L*** M n

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Basic Benefits including 100% Part B coinsurance

Hospitalization and Preventive Care paid at 100%; other Basic Benefits paid at 50%

Hospitalization and Preventive Care paid at 100%; other Basic Benefits paid at 75%

Basic Benefits including 100% Part B coinsurance

Basic Benefits

including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance

50% Skilled Nursing

Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance Skilled Nursing Facility Coinsurance

Part A Deductible Part a _Deductible Part A Deductible Part a _Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part a Deductible

Part B

Deductible Part B Deductible

Part B Excess

(100%) Part B Excess (100%)

foreign travel

Emergency Foreign Travel Emergency

foreign travel Emergency

Foreign Travel

Emergency Foreign Travel Emergency foreign travel Emergency

100% after $4,940 Out-of-pocket Annual Limit

100% after $2,470 Out-of-pocket Annual Limit

*NOTE: Plan f also has an option called a high-deductible Plan F. This high deductible plan pays the same

benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

BASIC BENEFITS: Included in all plans.

Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses), or copayments for hospital outpatient services. Plans K, L and N require insureds to pay a portion of Part B

coinsurance or copayments.

Blood: First three pints of blood each year.

Hospice: Part A coinsurance.

** For Plan K: You will pay one-half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,940 for the calendar year. Once you reach the annual limit, the plan pays 100% of your

Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include

charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

*** For Plan L: You will pay one-half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,470 for the calendar year. Once you reach the annual limit, the plan pays 100% of

your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT

include charges from your provider that exceed Medicare-approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.

Medicare (Part A) Hospital Services Per Benefit Period

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n hosPitalization1

Semi-private room and board, general nursing and miscellaneous services and supplies

• First 60 days All but $1,260 $0 $1,260 (Part A

deductible) $1,260 (Part A deductible) $0 $1,260 (Part A deductible) $0 $1,260 (Part A deductible) $0

• 61st _{thru 90}th _{day All but $315 a day $315 a day $0 $315 a day $0 $315 a day $0 $315 a day $0}

• 91st _{day and after while using 60 lifetime}

reserve days All but $630 a day $630 a day $0 $630 a day $0 $630 a day $0 $630 a day $0

Once lifetime reserve days are used:

• Additional 365 days $0 100% of Medicare-eligible

expenses

$02 _{100% of}

Medicare-eligible expenses

$02 _{100% of}

Medicare-eligible expenses

$02 _{100% of}

Medicare-eligible expenses

$02

• Beyond additional 365 days $0 $0 All costs $0 All costs $0 All costs $0 All costs

skilleD nursing facility care1 You must meet Medicare’s requirements, including having been in a hospital for at least three days and having entered a Medicare-approved facility within 30 days of leaving the hospital

• First 20 days All approved

amounts $0 $0 $0 $0 $0 $0 $0 $0

• 21st _{through 100}th _{day All but $157.50}

a day $0 Up to $157.50a day Up to $157.50 a day $0 Up to $157.50 a day $0 Up to $157.50 a day $0

• 101st _{day and after $0 $0 All costs $0 All costs $0 All costs $0 All costs}

BlooD

• First three pints $0 Cost of 3 pints $0 Cost of 3 pints $0 Cost of 3 pints $0 Cost of 3 pints $0

• Additional amounts 100% $0 $0 $0 $0 $0 $0 $0 $0

hosPice care

You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited

coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurnace

$0 Medicare

copayment/ coinsurance

$0 Medicare

copayment/ coinsurance

$0 Medicare

copayment/ coinsurance

$0

1. A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 2. When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid up to an additional 365 days as provided in the policy’s “Basic Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Medicare (Part A) Hospital Services Per Benefit Period

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n hosPitalization1

Semi-private room and board, general nursing and miscellaneous services and supplies

• First 60 days All but $1,260 $0 $1,260 (Part A

deductible) $1,260 (Part A deductible) $0 $1,260 (Part A deductible) $0 $1,260 (Part A deductible) $0

• 61st _{thru 90}th _{day All but $315 a day $315 a day $0 $315 a day $0 $315 a day $0 $315 a day $0}

• 91st _{day and after while using 60 lifetime}

reserve days All but $630 a day $630 a day $0 $630 a day $0 $630 a day $0 $630 a day $0

Once lifetime reserve days are used:

• Additional 365 days $0 100% of Medicare-eligible

expenses

$02 _{100% of}

Medicare-eligible expenses

$02 _{100% of}

Medicare-eligible expenses

$02 _{100% of}

Medicare-eligible expenses

$02

• Beyond additional 365 days $0 $0 All costs $0 All costs $0 All costs $0 All costs

skilleD nursing facility care1 You must meet Medicare’s requirements, including having been in a hospital for at least three days and having entered a Medicare-approved facility within 30 days of leaving the hospital

• First 20 days All approved

amounts $0 $0 $0 $0 $0 $0 $0 $0

• 21st _{through 100}th _{day All but $157.50}

a day $0 Up to $157.50a day Up to $157.50 a day $0 Up to $157.50 a day $0 Up to $157.50 a day $0

• 101st _{day and after $0 $0 All costs $0 All costs $0 All costs $0 All costs}

BlooD

• First three pints $0 Cost of 3 pints $0 Cost of 3 pints $0 Cost of 3 pints $0 Cost of 3 pints $0

• Additional amounts 100% $0 $0 $0 $0 $0 $0 $0 $0

hosPice care

You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited

coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurnace

$0 Medicare

copayment/ coinsurance

$0 Medicare

copayment/ coinsurance

$0 Medicare

copayment/ coinsurance

$0

1. A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 2. When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and

Medicare (Part B) Medical Services Per Calendar Year

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n meDical exPenses

In or Out of the Hospital and Outpatient

Hospital Treatment such asphysician’s

services, inpatient/outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

• First $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Generally 20% $0 Balance, other

than up to $20 per office visit and up to $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency room visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency room visit is covered as a Medicare Part A expense.

Part B excess charges

(above Medicare-approved amounts) $0 $0 All costs $0 All costs 100% $0 $0 All costs

BlooD

• First three pints $0 All costs $0 All costs $0 All costs $0 All costs $0

• Next $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

• Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0

clinical laBoratory services or tests for Diagnostic

services

100% $0 $0 $0 $0 $0 $0 $0 $0

3. Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted

Medicare (Part B) Medical Services Per Calendar Year

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n meDical exPenses

In or Out of the Hospital and Outpatient

Hospital Treatment such asphysician’s

services, inpatient/outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

• First $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

• Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0 Generally 20% $0 Balance, other

than up to $20 per office visit and up to $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency room visit is covered as a Medicare Part A expense.

Up to $20 per office visit and up to $50 per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency room visit is covered as a Medicare Part A expense.

Part B excess charges

(above Medicare-approved amounts) $0 $0 All costs $0 All costs 100% $0 $0 All costs

BlooD

• First three pints $0 All costs $0 All costs $0 All costs $0 All costs $0

• Next $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

• Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0

clinical laBoratory services or tests for Diagnostic

services

100% $0 $0 $0 $0 $0 $0 $0 $0

3. Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted

Medicare (Parts A & B) Services

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n home health care

Medicare-Approved Services

• Medically necessary skilled care services

and medical supplies 100% $0 $0 $0 $0 $0 $0 $0 $0

• Durable medical equipment

- First $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

- Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0

Other Benefits Not Covered by Medicare

meDicare

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

• First $250 each calendar year $0 $0 All costs $0 $250 $0 $250 $0 $250

• Remainder of charges $0 $0 All costs 80% to a

lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum

80% to a lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum

80% to a lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum 3. Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted

Medicare (Parts A & B) Services

Medicare Pays Plan A Health

Alliance Pays You PayPlan a Plan C Health Alliance Pays You PayPlan c Plan F Health Alliance Pays You PayPlan f Plan N Health Alliance Pays You PayPlan n home health care

Medicare-Approved Services

• Medically necessary skilled care services

and medical supplies 100% $0 $0 $0 $0 $0 $0 $0 $0

• Durable medical equipment

- First $147 of Medicare-approved amounts3 _{$0 $0 $147 (Part B}

deductible) $147 (Part B deductible) $0 $147 (Part B deductible) $0 $0 $147 (Part B deductible)

- Remainder of Medicare-approved amounts 80% 20% $0 20% $0 20% $0 20% $0

Other Benefits Not Covered by Medicare

meDicare

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

• First $250 each calendar year $0 $0 All costs $0 $250 $0 $250 $0 $250

• Remainder of charges $0 $0 All costs 80% to a

lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum

80% to a lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum

80% to a lifetime maximum benefit of $50,000

20% and

amount over the $50,000 lifetime maximum 3. Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted