Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan.
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HealthAlliance.org/Medicare
Comfort of having an in-network primary care provider to oversee all your care.
Generally gives you the flexibility to see any doctor who accepts Original Medicare.
Replaces Original Medicare. May cover benefits that Original Medicare doesn’t.
Supplements Original Medicare. Only covers expenses covered by Original Medicare.
No medical underwriting.
Medical underwriting. (Except for guaranteed issue plans.)
Lower premiums than Medicare Supplement plans. Who pays in what order: health plan, you. Not age- or tobacco-rated.
Higher premiums than Medicare Advantage plans. Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated.
Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a fixed dollar amount (like $20), and coinsurance is a percentage (like 20%).
Drug tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups:
• Tier 1 (Preferred Generic).
• Tier 2 (Generic).
• Tier 3 (Preferred Brand).
• Tier 4 (Nonpreferred Drug).
• Tier 5 (Specialty Tier).
Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.
Emergency care: This is the care you receive at an emergency room (ER) or emergency department. When you believe your health is at serious risk, seek emergency department care immediately. Don't hesitate to call 911 for assistance.
Ground ambulance: What you pay for an ambulance ride in an emergency.
Inpatient hospital care: The amount you pay for a stay in an in-network hospital.*
Lab: What you pay for lab services, like blood tests.
Medical deductible: A set amount you pay before your plan starts helping pay for your medical care or pharmacy benefits.
Outpatient care: What you pay for medical care or treatment that doesn't include staying overnight in a hospital.
Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.
Premium: The monthly fee you pay for coverage.
Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
Skilled nursing facility (SNF): What you pay for an approved stay at a SNF.
Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.*
Urgent care: The amount you pay for urgent or convenient care.
Yearly limit: The most you'll pay in a coverage period before your plan pays 100% of covered expenses. It's also called the out-of-pocket maximum.
*Review the provider directory at HealthAlliance.org/Medicare for our in-network doctors and hospitals. With an HMO plan, you choose a primary care provider (or PCP) from our broad network. You’re not covered out of network unless it’s for emergency or urgent care.
With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You save money by staying in network, though.
Key: This is a summary of commonly used benefits.
IN means in network, and OON means out of network.
The OON yearly limit includes your combined costs for both in-network and out-of-network care.
† Members on POS plans may pay more for preventive care out of network.
» Non-emergency cost-sharing may vary. Contact the plan for details.
* Emergency care available worldwide.
+ Also called convenient or walk-in care.
^ You pay nothing for days 91 and beyond in network.
& Dollar amounts listed for inpatient hospital care and SNF are amounts you pay per day.
~ Refer to plan materials for specific coverage information.
Get help paying for dental services, like cleanings, X-rays and more, most plans cover up to $2,000 a year. (HMO Basic has a $1,500 limit and POS Choice Rx has a $3,000 limit.)
Vision Hardware Coverage
Get access to vision services beyond what Original Medicare covers, including a $200 annual allowance for eyewear. (HMO Basic has a $150 vision hardware allowance.)
Be Fit
Get fit with a $360/year benefit to use on a variety of fitness activities.
OTC Benefit
Save money with the over-the-counter supplemental benefit from Health Alliance. Get up to $140/year for commonly used OTC products. Visit HealthAlliance.NationsBenefits.com for more information.
Virta
Hally® health is excited to offer Virta Health: the virtual program which can help you reverse type 2 diabetes without the risks, costs or side effects of medications or surgery. Looking for a better way to conquer your type 2 diabetes and achieve real results within 10 weeks? With Virta Health, you got this!
*All perks aren’t available on all plans or to the general public.
*Participation in the program is not a guarantee that the member's diabetes will be reversed and that it requires active participation/ adherence by the member.
Hearing Benefit
Get one routine hearing exam for a $0 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.
Health Alliance Medical Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity). Health Alliance Medical Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity). Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame (800) 965-4022 (TTY: 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 (800) 965-4022 (TTY: 711).
Health Alliance Medicare is a HMO plan with a Medicare contract. Enrollment in Health Alliance Medicare depends on contract renewal.
Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Medicare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-ofnetwork services. Other pharmacies/physicians/providers are available within our network.