MAKE YOUR CURRENT HEALTH INSURANCE WORK BETTER FOR YOU Bridging The GAP.

MAKE YOUR CURRENTHEALTH INSURANCEWORK BETTER FOR YOU

Bridging The Bridging The GAPGAP

How will you prepare for Out-of-Pocket charges from hospital and doctors bills?As healthcare costs continue to increase, many individuals and

businesses are moving towards high-deductibles and

increased co-insurance on major medical plans in an effort to

reduce costs.

While this approach reduces the cost of your health insurance,

it puts you at greater financial risk. In fact, more than six in 10

adults who say they have problems paying their medical bills

are covered by health insurance.*

* Kaiser Family Foundation/Harvard School of Public Health Care Costs Survey

Bridging The GAPBridging The GAP

How will you prepare for Out-of-Pocket charges from hospital and doctors bills?Philadelphia American Life Insurance Company’s (PALIC) GAP Plan helps bridge the gaps in the coverage that exist in your current health insurance plan by reducing or even eliminating the Out-of-Pocket expenses that are associated with hospital and doctors bills.

Benefits payments are limited to the deductibles, co-pays and co-insurance amounts that you or each of your covered family members are required to pay under your Primary Medical Insurance


Benefit Options/ Rates/ Commissions To help bridge the coverage gap you can select an annual calendar maximum benefit starting as of low as $2,000 or a maximum benefit of $10,000 (in $1,000 increments).

Deductibles are available: $ 0, $250, $500 or $1,000.

Plan Rates are based on the highest age when including spouse. Example Individual & Spouse and Individual & Family.

Commissions will be paid at the same commission rate as the HSP product line for Guaranteed Issue enrollments with a higher 1st year commission for Simplified Issue regardless if it is an individual plan or list bill.


Benefits

We will pay Hospital Inpatient Benefits equal to 100% and Outpatient Benefits equal to 50% of any co-payments, deductibles or co-insurance for which You are responsible under Your Primary Medical Policy, up to the Maximum Annual Calendar Year Benefit you selected.

When you file a claim, please send the Explanation of Benefits provided by your Primary Medical Policy.

If a claim is filed within the 12 month pre-existing period a claim form is also required.


Excepted BenefitPALIC’s GAP Plan is considered an Excepted Benefit under the ACA and must follow a strict criteria to maintain this status. Some of the key elements that must be taken into consideration are:

The policy must be specifically designed to fill gaps in primary coverage, such as coinsurance or deductibles.

The policy must be supplemental and issued by an entity that does not provide the primary coverage.

The cost of coverage under the supplemental policy must not exceed 25% of the cost of the primary coverage. This requirement does NOT apply to Short-Term Major Medical since STM is not considered an Excepted Benefit under the ACA.

• By including the deductible options with the GAP plan it allows you more flexibility in meeting the ACA this requirement for Excepted Benefit plans : $250 / $500 / $1,000

• You can also sell less: Instead of $5,000 sell 80% or $4,000


Excepted Benefit Percentage Individual Age 38

GAP Plan

Benefit: $ 6,000Premium: $ 42.80 Percentage: 12.9%

GAP Plan

Benefit: $ 4,000Premium: $ 34.30Percentage: 9%

Benefit: $ 3,000 Premium: $ 29.00 Percentage: 7.6%


Excepted Benefit Percentage Male, Female age 38 & 2 Children

GAP Plan


GAP Plan


Benefit: $ 3,000 Premium: $ 101.90 Percentage: 8.8%


In which plan would you be better off ? GAP Plan

Benefit: $ 6,000Premium: $ 156.30 Bronze Level $ 1,002.00

Total $ 1,158.30

VERSUSYou save almost $500 a month plus the Platinum Plan still has a $950 Deductible


Rates Inpatient Deductible $ 0

Total Annual Benefit AmountAttained Age 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000

<40 Insured Only 24.00 29.00 34.30 40.40 42.80 46.20 48.40 51.70 53.90 40-49 Insured Only 38.80 45.10 52.80 61.30 67.90 73.30 77.20 82.50 86.80

50+ Insured Only 60.10 68.50 80.50 93.50 104.60 113.70 120.40 129.60 136.80

<40 Insured & Spouse 48.00 58.00 68.50 80.80 85.50 92.40 96.80 103.40 107.80

40-49 Insured & Spouse 77.60 90.10 105.50 122.60 135.80 146.50 154.40 165.00 173.50

50+ Insured & Spouse 120.20 137.00 160.90 187.00 209.20 227.40 240.80 259.10 273.60

<40 Insured & Children 55.00 68.00 78.30 91.70 102.90 108.60 114.00 119.60 123.80

40-49 Insured & Children 72.80 87.10 100.00 116.00 129.10 136.50 143.50 150.70 156.70 50+ Insured & Children 91.10 113.20 123.60 143.00 159.50 169.60 178.40 188.60 196.70

<40 Insured & Family 83.00 101.90 118.20 139.00 156.30 167.00 176.00 186.10 193.60 40-49 Insured & Family 117.20 138.80 160.40 186.60 207.90 222.10 234.50 248.20 259.60

50+ Insured & Family 152.40 187.40 206.60 239.70 268.20 288.20 304.70 324.70 340.80


Example of Inpatient BenefitPALIC’s GAP Plan will help by paying your in-patient hospital expenses for plan deductibles and co-insurance which are not paid by your Primary Medical Insurance Policy but are still considered eligible expenses by your Primary Medical Insurance Policy

Without GAP Benefits

With $5,000 GAP Benefits

Deductible $2,500 $2,500

Co-Insurance @ 20% Out-of-Pocket

$2,600

$2,600

Minus GAP Benefit $0 ($5,000)

Total Out-of-Pocket $5,100 $100

Hospital Admission + Surgery = $15,500


Example of Outpatient BenefitOutpatient expenses are paid at 50% of the eligible outpatient expenses related to your co-insurance and / or deductible. These expenses must be considered eligible expenses under your Primary Medical plan but are not paid by the plan.

Without GAP Benefits

With GAP Benefits

Applied to Deductible $150 $150

Paid by Primary Medical $0 $0

Minus GAP Benefit @ 50% of Outpatient

$0 ($ 75)

Total Out-of-Pocket $150 $ 75

Doctor office visit = $150


Outpatient Benefits (Policy)We will pay Outpatient Benefits equal to 50% of any copayments, deductibles or coinsurance as outlined below for which You are responsible under Your Primary Medical Policy, up to the Maximum Annual Benefit each calendar year, for You or a Family Member covered under the Primary Medical Policy. Expenses for Outpatient Benefits include:•Facility and Physician expenses for outpatient surgery in a Hospital or free-standing outpatient surgery center•Facility and Physician expenses for outpatient diagnostic testing in a Hospital or free-standing imaging facility or free-standing laboratory

•Hospital and Physician expenses for treatment in an emergency room

•Hospital and Physician expenses for other outpatient treatment in a Hospital

•Copayments for Physician’s office visits (deductibles or coinsurance are not eligible

expenses) This benefit has been changed by amendment see next slide


Outpatient Benefits (Amendment)AMENDMENT – Effective January 1, 2014

This Amendment is effective as of the later of January 1, 2014 or the Effective Date shown in the Policy Schedule of Benefits.

The Benefits, Outpatient Benefits, Expenses for Outpatient Benefits include, section of Your Policy is amended by:

Deleting the following:Copayments for Physician’s office visits (deductibles or coinsurance are not eligible expenses)

Adding the following:Physician’s office visits

This Amendment is attached to and made a part of the policy


Outpatient BenefitsWe will pay Outpatient Benefits equal to 50% of any copayments, deductibles or coinsurance as outlined below for which You are responsible under Your Primary Medical Policy, up to the Maximum Annual Benefit each calendar year, for You or a Family Member covered under the Primary Medical Policy. Expenses for Outpatient Benefits include:•Facility and Physician expenses for outpatient surgery in a Hospital or free-standing outpatient surgery center•Facility and Physician expenses for outpatient diagnostic testing in a Hospital or free-standing imaging facility or free-standing laboratory

•Hospital and Physician expenses for treatment in an emergency room

•Hospital and Physician expenses for other outpatient treatment in a Hospital

•Copayments for Physician’s office visits (deductibles or coinsurance are not eligible expenses) This is what the Amendment accomplished


Bucket of MoneyThink of the GAP benefit as purchasing a bucket of money at a fraction of the cost to help offset the expense associated with your medical deductible and co-insurance.


Bucket of MoneyYou will take enough money out of the bucket to pay for your plan’s Deductible.

Deductible


Bucket of MoneyYou will also take enough money out of your bucket to pay your Co-insurance amount.

Co-Insurance Deductible


Bucket of MoneyAnd then each calendar year we will refill the bucket up to your annual pre-selected amount.


Approved States

AK

OR

NV

AZ

TX LA

AR

MOKS

NEIA

MSAL GA

FL

IL INOH

KY

WVVA

PA

HI

WI

CA

ID

MT

WY

WA

UT CO

NMOK

SD

ND

MN

TNSC

NC

MI

ME

NY

Approved States

Filed Pending Approval


GAP

PROTECTION

Completing The Healthcare Puzzle

MAKE YOUR CURRENT HEALTH INSURANCE WORK BETTER FOR YOU Bridging The GAP.

Documents

primary medical insurance

primary coverage

primary medical policy

medical bills

current health insurance

individual plan

cost of coverage

increased coinsurance