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FREQUENTLY ASKED QUESTIONS  
 

ABOUT MEDICARE ADVANTAGE PLANS
What are Medicare Advantage plans?
Do I lose my Medicare benefits when I join HAP Senior Plus or Alliance Medicare PPO?
Can I enroll in both a Medicare Advantage plan and a stand-alone prescription drug plan?
Can you cancel my plan?
What happens if I just keep my Original Medicare plan?
Will I have to submit claims for any services I receive?
What is the difference between a deductible and coinsurance?
What is a copay?

MEDICARE ADVANTAGE PLAN NETWORKS
Can I go to any doctor or hospital I want?
Will I have trouble getting a referral to a specialist? What if my personal care physician won't refer me to a specialist?
Can I use my specialist as my personal care physician?
I see two doctors that I use and both are in your HAP Senior Plus plan. The Specialist is in one network and the Internal Medicine doctor is in another. Am I able to use them both?
What do I do if I would like to switch my doctor?
What role does my PCP play in urgent and emergency care?

MEDICARE ADVANTAGE PLAN COVERAGE
What if I have a pre-existing condition? Will I be able to join now or will I have to wait for medical treatments for that condition?
Do you cover long-term care or nursing home care?
What happens if I go to the emergency room for something I thought required immediate medical attention, and find out it was not an emergency?
What is an urgent medical condition?
What is an emergency medical condition?
What is the difference between urgent and emergency care?
Why is it important to know the difference between urgent and emergency conditions?
What should I do when I'm traveling?
How can I get more information about Medicare benefits?

About Medicare Part D plans
Do I have to get prescription drug coverage?
I have Original Medicare, and I'm not sure I need prescription drug coverage.
What is creditable coverage?
I don't use a lot of prescriptions. Should I still consider prescription drug coverage?
What if I already have prescription drug coverage from a former employer?

About Alliance Medicare Part D
Can I get a prescription drug plan through HAP?
How will I know if the drug I take is covered?
What if my prescription drug is not on your formulary?
How will I know if I've reached my limit on prescription coverage?

About Medicare Supplement (Medigap) Plans
What is a Medigap policy?
How do I know if I am I eligible for Alliance Medicare Supplement?
When can I sign up for Alliance Medicare Supplement?
Am I covered when I travel?
Do I need a referral to see a specialist?
Can I keep my Alliance Medicare Supplement policy if I move out of state?
If I have a Medigap policy, how can I get prescription drug coverage?

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About Medicare Advantage Plans

WHAT ARE MEDICARE ADVANTAGE PLANS?
Medicare Advantage plans are an alternative to Original Medicare. These plans provide an equivalent or better level of coverage. HAP has a contract with the federal Medicare program to coordinate your Medicare benefits and provide for your medical coverage. In other words, Medicare pays us and we cover you.

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DO I LOSE MY MEDICARE BENEFITS WHEN I JOIN HAP SENIOR PLUS OR ALLIANCE MEDICARE PPO?
No. You are still in the Medicare program. In fact, you must have and keep both Medicare Part A and Part B in order to enroll in our Medicare Advantage plan. We have a contract with the federal government to provide our plans to Medicare beneficiaries.

As a member of HAP Senior Plus or Alliance Medicare PPO, you receive all of your Medicare-covered services through your plan. Your benefits include all the benefits you are entitled to under Medicare, including the option for prescription drug coverage. Plus, you get a full range of additional health care benefits, including  our Flexible Health Options benefit and worldwide emergency and urgent care coverage. See the Summary of Benefits for more information.

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CAN I ENROLL IN BOTH A MEDICARE ADVANTAGE PLAN AND A STAND-ALONE PRESCRIPTION DRUG PLAN?
No. Medicare does not allow enrollment in multiple Medicare-approved plans. Medicare Advantage plans with prescription drugs include both medical and Part D prescription drug coverage, so there is no need to enroll in an additional drug plan.

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CAN YOU CANCEL MY PLAN?
Generally, you cannot be cancelled involuntarily unless you do one of the following:

• Cancel your Medicare Part B coverage
• Permanently move out of the plan's service area
• Leave the plan's service area for an extended absence of more than six continuous months
• Fail to make a scheduled payment

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Medicare Advantage plans and Medicare prescription drug plans have contracts with Medicare, and agree to stay in the program for a full year at a time. Each year, that contract is renewed. If your plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. Even if your plan leaves the program, you will not lose Medicare coverage. You would still have Original Medicare or you could enroll in a different Medicare-approved plan.

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WHAT HAPPENS IF I JUST KEEP MY ORIGINAL MEDICARE PLAN?
There are gaps in the coverage Original Medicare provides. Medicare pays a share of the Medicare-approved amount, and you pay your share which includes coinsurance, copays and up-front deductibles. In some cases, you may be charged more than the Medicare-approved amount. If you experience a serious illness or have multiple conditions, these out-of-pocket costs can become significant. With a Medicare Advantage plan, these costs may be less.

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WILL I HAVE TO SUBMIT CLAIMS FOR THE SERVICES I RECEIVE?
As an HMO, HMO-POS, or PPO member, you do not have to submit claim forms for services provided by network providers. For example, if you see your doctor for an annual checkup, your doctor will bill us and you pay your copay. If you have an emergency or urgent care situation while out of our service area, you may be required to pay for services when you receive them, and then submit a claim for reimbursement by mailing a copy of the claim to us. If you use routine services out-of-network under your HMO-POS option or with PPO coverage, you may also need to submit a claim for reimbursement.

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WHAT IS THE DIFFERENCE BETWEEN A DEDUCTIBLE AND COINSURANCE?
A deductible is the amount you must pay for health care services, before Medicare begins to pay. The deductible amount can change every year. Coinsurance is a percentage (generally 20%) of the Medicare-approved amount that you must pay after you pay your deductible.

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WHAT IS A COPAY?
A copay is a set amount you pay for medical services. For example, for a doctor's office visit, your copay may be $15 or $20.

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MEDICARE ADVANTAGE PLAN NETWORKS

CAN I GO TO ANY DOCTOR OR HOSPITAL I WANT?
As a member of Alliance Medicare PPO, you can use any Medicare-participating provider. When you use a provider within our contracted network, you receive the maximum benefit. Services received for routine care from Medicare-participating providers outside of our network will generally cost more (i.e., have higher copay and coinsurance costs). You are also covered for emergencies and urgent care anywhere in the world and renal dialysis services out of area but within the U.S. at the same copay you pay at home.

As a member of HAP Senior Plus (hmo)-Henry Ford, your primary and specialty care are provided within the Henry Ford Health System. The Personal Care Physician (PCP) you choose coordinates all the services and care you need through the select hospitals, doctors, and specialists affiliated with this plan. You are covered for emergencies and urgent care services worldwide. You are also covered in the U.S. for out-of-area renal dialysis. For all other routine care, you must use providers within our network. If you obtain routine care from out-of-network providers, neither HAP Senior Plus-Henry Ford nor Medicare will be responsible for the costs.

As a member of HAP Senior Plus (hmo-pos)-Expanded Network, you have a Point-of-Service option (POS). Your Personal Care Physician (PCP) will coordinate your care and make arrangements for you, as necessary, to see other affiliated doctors and hospitals. You are covered for emergencies and urgent care anywhere in the world and renal dialysis services out of area but within the U.S.. You are covered for routine care outside the plan network with a 20% coinsurance for up to $1,000, $1,500 or $2,000 of care based on plan choice. Cost may be higher than in-network. For all other routine care, you must use providers within our network. If you obtain routine care from out-of-network providers, neither HAP Senior Plus-Expanded Network nor Medicare will be responsible for the costs.

In every plan, you must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party.

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WILL I HAVE TROUBLE GETTING A REFERRAL TO A SPECIALIST?
Our primary focus is to keep you well. That means you will be able to see a specialist whenever there is a medical reason to do so. With HAP Senior Plus, your Personal Care Physician (PCP) will help coordinate your specialty care.
As a member of Alliance Medicare PPO, you can see any Medicare-participating doctor. For more detailed information:

If you are selecting a plan, please refer to the Summary of Benefits
If you are already a PPO plan member, call a Client Services Specialist at the phone number listed on the back of your member ID card.

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CAN I USE MY SPECIALIST AS MY PERSONAL CARE PHYSICIAN?
With HAP Senior Plus, you select a Personal Care Physician (PCP). PCPs, known as Internal Medicine (Internists) or Family Practice doctors, have had special study and training in the prevention and treatment of conditions that affect adults. Internists are sometimes referred to as the "doctor's doctor," because they are often called upon to act as consultants to other physicians to help solve puzzling diagnostic problems.

Your Personal Care Physician, who is a trained professional, will help coordinate your specialty care. PCPs also bring to patients an understanding of wellness, disease prevention and the promotion of health.

HAP stresses preventive care and encourages you to establish a relationship with your PCP. Keep in mind, specialists receive training that tends to make them focus on one part of your body. A Personal Care Physician looks at all the care you are receiving from all specialists. A PCP, for example, can help ensure that prescriptions provided by different specialists will not conflict with each other. In fact, recent studies have shown that almost 10 percent of all older adults are taking combinations of medications that could be dangerous - in other words, they are over-medicated.

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I SEE TWO DOCTORS THAT I USE, AND BOTH ARE IN YOUR HAP SENIOR PLUS PLAN. THE SPECIALIST IS IN ONE NETWORK AND THE INTERNAL MEDICINE DOCTOR IS IN ANOTHER. CAN I USE THEM BOTH?
The answer depends on which HAP Senior Plus plan you select.

If you live in Wayne, Oakland or Macomb County and you select HAP Senior Plus (hmo)-Henry Ford, your primary and specialty care are provided within the Henry Ford Health System. The Personal Care Physician (PCP) you choose coordinates all the services and care you need through the select hospitals, doctors, and specialists affiliated with this plan. The physician groups affiliated with this plan are the Henry Ford Medical Group (HFMG), Wyandotte IPA, and Macomb. If the PCP you select is within the HFMG, you will also receive specialty care services from doctors within that group. If your choice of PCP is part of the Wyandotte IPA or Macomb, your PCP will still coordinate your care, but you may seek needed care from any HAP Senior Plus-Henry Ford affiliated specialist.

HAP Senior Plus (hmo-pos)-Expanded Network serves people with Medicare who live in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair, or Washtenaw county. Though your Expanded Network PCP may recommend specialty services from a particular specialist or facility, you can choose to receive needed care from any HAP Senior Plus-Expanded Network contracted specialist.

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WHAT DO I DO IF I WOULD LIKE TO SWITCH MY DOCTOR?
You can either call our Client Services department to request help with selecting or changing your PCP or you can go online and make the change.

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WHAT ROLE DOES MY PERSONAL PHYSICIAN PLAY IN URGENT AND EMERGENCY CARE?

Your personal physician has a very important role in every aspect of your health care including urgent and emergency care. BEFORE the need arises contact your personal physician's office for instructions regarding urgent and emergency situations. This is especially important if you are a member of HAP Senior Plus. Your Personal Care Physician will help arrange in-network follow-up care.

Remember, your personal physician can be your partner in maintaining your health no matter which health plan you choose.

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MEDICARE ADVANTAGE PLAN COVERAGE

WHAT IF I HAVE A PRE-EXISTING CONDITION? WILL I BE ABLE TO JOIN NOW OR WILL I HAVE TO WAIT FOR MEDICAL TREATMENTS FOR THAT CONDITION?
All of your plan benefits start the first day your Medicare Advantage plan coverage takes effect. There are no exclusions or waiting periods for pre-existing conditions. The only medical condition that would prevent you from joining is End Stage Renal Disease, unless you already are a member of a HAP plan. Once you are a Medicare Advantage member, your rates cannot be raised for any medical condition and you cannot be canceled for any medical condition.

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DO YOU COVER LONG-TERM CARE OR NURSING HOME CARE?
Neither Medicare Advantage plans nor Medicare Supplemental insurance cover long-term care needs. This benefit would be covered under a long-term care insurance policy that you purchase separately.

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WHAT HAPPENS IF I GO TO THE EMERGENCY ROOM FOR SOMETHING I THOUGHT REQUIRED IMMEDIATE MEDICAL ATTENTION, AND FIND OUT IT WAS NOT AN EMERGENCY?
We encourage you to seek medical care when you feel it is necessary. If you believe you are having an emergency, go to the emergency room for medical treatment. Your plan will pay the claim based on why you went to the emergency room, not on the diagnosis or final outcome of your treatment.

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WHAT IS AN URGENT MEDICAL CONDITION?
Sprained ankles, most burns, minor wounds requiring stitches, back pain, chronic headaches, urinary tract infections and severe cold or flu are typical examples of urgent conditions. An urgent condition is not life-threatening but may require prompt attention. Urgent care access standards require care on the same day or next day depending on the severity of the condition.

Contact your Personal Care Physician's (PCP's) office for urgent care instructions. Often urgent care conditions may be treated in your physician's office. When you call with an urgent need, request a same or next day appointment. Your PCP has appointments available for patients with urgent conditions. In fact, it is better to visit your PCP in an urgent situation rather than going to an emergency room because your PCP is aware of your medical history and any care that you are currently receiving. If your PCP is not available and other arrangements cannot be made through his or her office, you may go to any HAP-affiliated urgent care facility. If you are outside of our service area, you may seek urgent care at any urgent care facility.

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WHAT IS AN EMERGENCY MEDICAL CONDITION?
A "medical emergency" occurs when you reasonably believe that your health is in serious danger and every second counts. A medical emergency includes severe pain, a bad injury, a serious illness or a medical condition that is quickly getting much worse.

Emergency care is available 24 hours a day, seven days a week at emergency facilities. If you experience a medical emergency, go to the nearest emergency facility or call 911 for assistance. After a visit to an emergency room, you should follow up with your PCP. This ensures that any additional care will be coordinated through your PCP, that your medical records and history are updated, and that your treatment reflects any existing conditions or medications.

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WHAT IS THE DIFFERENCE BETWEEN URGENT AND EMERGENCY CARE?
Emergency care is more serious than urgently needed care. Emergencies are most commonly treated at a hospital emergency room. Urgent needs can often be treated by your PCP. If an urgent need arises when you are traveling, it can usually be treated at an urgent care center.

In both cases, the need is unexpected, could not have been scheduled, and should not wait for treatment at some future date.

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WHY IS IT IMPORTANT TO KNOW THE DIFFERENCE BETWEEN URGENT AND EMERGENCY CONDITIONS?

Knowing the difference between urgent and emergency medical conditions will help you determine how to obtain the most appropriate care, can save you costly copays and can ensure that you are treated as quickly as your condition requires.

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WHAT SHOULD I DO WHEN I'M TRAVELING?
Our Medicare Advantage plans offer worldwide health care coverage for medical emergencies, accidental injuries and urgent care. Remember that, in an emergency situation, you can always call 911 in the United States or go to the nearest emergency room.

Generally, the site where you seek care will ask for your health insurance card (your HAP or Alliance ID card) and call the number on the back for billing or coverage questions. If the physician or hospital does not recognize your ID card and requires immediate payment for services, you are responsible for paying the hospital or physician. We will fully reimburse you for the covered services less any copays you are required to pay. Just send your receipts to:

Health Alliance Plan
Attention: Member Reimbursement
2850 W. Grand Blvd.
Detroit, Michigan 48202

If you are admitted to a hospital not affiliated with us, you or your designee should notify us within 48 hours at the number listed on the back of your ID card.

You can review a complete list of approved Urgent Care Centers within our 9 county service area by going to www.hap.org. Click on the Find a Doctor/Facility tab, and then click on Urgent Care Centers in the Related Links section on the left side of the page.

For information about follow-up care, please see your plan's Summary of Benefits for out-of-network or out-of-area routine coverage.

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HOW CAN I GET MORE INFORMATION ABOUT MEDICARE BENEFITS OR HAP'S MEDICARE SOLUTIONS?
If you are not a HAP member, you can order a free educational booklet or educational DVD. Please call a licensed HAP Medicare Sales Representative toll-free at:

(800) 868-3153 or TTY/TDD (800) 649-3777

Monday through Friday, 8 a.m. to 5 p.m.

Your HAP Medicare Sales Representative can also provide information and answer questions about benefits and coverage.

If you are a HAP member, call Client Services toll-free at:

Alliance Medicare Rx (800) 765-3436
Alliance Medicare PPO (888) 658-2536
HAP Senior Plus (800) 801-1770
TTY/TDD (800) 649-3777

Office Hours:
Monday through Friday, 8 a.m. to 8 p.m.
Saturday, 8 a.m. to noon.

At all other times, you may access our Interactive Voice Recording system at the same number and leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day.

Extended hours from October 15 - February 14:
7 days a week, 8 a.m. to 8 p.m.

You can also contact Medicare at www.medicare.gov on the Web. Or call Medicare toll-free at (800) MEDICARE ((800) 633-4227), 24 hours a day, seven days a week. TTY users should call (877) 486-2048.

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ABOUT MEDICARE PART D PLANS

DO I HAVE TO GET PART D PRESCRIPTION DRUG COVERAGE?

No. You can enroll in a HAP Senior Plus plan without prescription drug coverage. However, if you decide at a future date to elect Part D prescription drug coverage, you may pay a financial penalty assessed by Medicare.

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I HAVE ORIGINAL MEDICARE, AND I'M NOT SURE I NEED PRESCRIPTION DRUG COVERAGE.
If you do not use a lot of prescription drugs now, you should still consider enrolling in a Part D plan. As people age, they often need prescription drugs to stay healthy. Joining now will secure the lowest possible plan premium. If you wait to join, you may pay a penalty.

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WHAT IS CREDITABLE COVERAGE?
"Creditable coverage" is the term the government uses to describe prescription-drug coverage that is at least as good as or better than what Medicare offers. If you are enrolled in Medicare and have a drug benefit through an employer's health plan, that coverage is likely to qualify as "creditable coverage." If you lose those drug benefits, you will receive a certificate of creditable coverage that guarantees your right to buy a Medicare Part D plan within specified timeframes without paying a penalty for late enrollment.

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I DON'T USE A LOT OF PRESCRIPTIONS. SHOULD I STILL CONSIDER PRESCRIPTION DRUG COVERAGE?
By joining a plan now with prescription drug coverage, you can keep your premium costs low, and protect against unexpected expenses in the future. If you do not currently have creditable coverage, and you wait past the time you are initially eligible to enroll in a Part D plan, you may have to pay a penalty of 1% for every month you delayed enrollment. This penalty would continue through the rest of your years with Medicare Part D coverage.

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WHAT IF I ALREADY HAVE PRESCRIPTION DRUG COVERAGE FROM A FORMER EMPLOYER?
If you have prescription drug coverage now through your employer, you should review your plan and talk to your plan benefits administrator or insurer before making any changes. You will be notified by your employer about any changes to your current coverage so you can decide if a different plan is a better choice for you.

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ABOUT ALLIANCE MEDICARE PART D

CAN I GET A PRESCRIPTION DRUG PLAN THROUGH HAP?
Yes. You choose what is best for you. You can enroll in Alliance Medicare Rx, our stand-alone Prescription Drug Plan. Or you can enroll in one of our Medicare Advantage plans that include Medicare Part D prescription drug benefits.

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HOW WILL I KNOW IF THE DRUG I TAKE IS COVERED?
Each Medicare Part D plan provides its own list of covered drugs, which is called a formulary. There are three ways you can find out if we cover a drug you are taking.

Download the formulary list in all plans we offer that include Medicare Part D prescription drug benefits

Call a licensed HAP Medicare Sales Representative toll-free with questions or for assistance with coverage, medications, or available pharmacies at:

(800) 868-3153 or TTY/TDD (800) 649-3777

If you are a current HAP or Alliance member, call Client Services toll-free at:

HAP Senior Plus (800) 801-1770
Alliance Medicare PPO (888) 658-2536
Alliance Medicare Rx (800) 765-3436
TTY/TDD (800) 649-3777

Office Hours:
Monday through Friday, 8 a.m. to 8 p.m.
Saturday, 8 a.m. to noon.

At all other times, you may access our Interactive Voice Recording system at the same number and leave your name and phone number. A HAP Medicare Customer Service Representative will return your phone call the next business day.

Extended hours from October 15 - February 14:
7 days a week, 8 a.m. to 8 p.m.

Or write to us at:
HAP Client Services
Attn: Medicare
2850 W. Grand Boulevard
Detroit, Michigan 48202

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WHAT IF MY PRESCRIPTION DRUG IS NOT ON YOUR FORMULARY?
If you are taking a drug that is not on our formulary, you can talk with your doctor about whether a different drug might be an effective alternative for you. If an effective alternative is not available, you or your doctor can request an exception to allow coverage of the drug you use.

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HOW WILL I KNOW IF I HAVE REACHED MY LIMIT ON PRESCRIPTION COVERAGE?
Each month, you receive a statement of activity that shows:

Your out-of-pocket cost to date
The total amount paid by the plan
The remaining benefit amount

This statement is called the Explanation of Benefits, and eliminates unpleasant surprises at the pharmacy. If you are concerned about the Coverage Gap (or "Donut Hole"), you may want to consider one of our Medicare Advantage plans that provides coverage for Generic and Brand-Name drugs through the Coverage Gap.

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ABOUT MEDICARE SUPPLEMENT (MEDIGAP) PLANS

WHAT IS A MEDICARE SUPPLEMENT OR MEDIGAP POLICY?

A Medicare Supplement insurance policy (also known as Medigap) is sold by private insurance companies to fill "gaps" in Original Medicare plan coverage. This policy helps pay your share of hospital and medical costs - your coinsurance, copays and deductibles. Medigap policies only work with the Original Medicare plan and do not include any benefits not covered by Medicare (such as dental, eyeglasses or HAP's Flexible Health Options benefit).

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HOW DO I KNOW IF I AM I 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 pay the monthly Medicare Part B premium. In addition, you will have to pay a monthly premium for your Alliance Medicare Supplement policy.

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WHEN CAN I SIGN UP FOR ALLIANCE MEDICARE SUPPLEMENT?
You can purchase Alliance Medicare Supplement at any time. The best time to purchase your policy is when you become eligible for Medicare and enroll in Medicare Part B. Any pre-existing condition may be excluded from coverage for the first six months you are enrolled in a Medicare Supplement.

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AM I COVERED WHEN I TRAVEL?
Yes. Your coverage goes with you anywhere in the United States. With Plan C, Plan F, or Plan N, you also have worldwide emergency coverage.

Alliance Medicare Supplement policy holders also have the added protection of global emergency assistance services through our partnership Assist America®.

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DO I NEED A REFERRAL TO SEE A SPECIALIST?
With Alliance Medicare Supplement, you can see any doctor or specialist who participates in Medicare. No referrals are required.

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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 live as long as you are still in the Original Medicare plan and maintain your Part B coverage.

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HOW CAN I GET PRESCRIPTION DRUG COVERAGE?
If you are interested in Medicare prescription drug benefits in addition to your Alliance Medicare Supplement plan, we invite you to consider Alliance Medicare Rx (pdp). Alliance Medicare Rx is a Medicare-approved Part D stand-alone Prescription Drug Plan (PDP) that offers affordable prescription drug coverage. Just give us a call, and we will be happy to discuss Alliance Medicare Rx with you and send you information.

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