Outline of Medicare Supplement Coverage · 2020. 5. 5. · Benefit Chart of Medicare Supplement...

TF34726VA N7-19 page 1 Rev. 5-2020

Outline of Medicare Supplement Coverage Cover page 1 of 2

Benefit Chart of Medicare Supplement Plans Sold with Effective Dates on or after June 1, 2010

Plans A, F, G, N 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.

Plans C, F, and high deductible F are no longer available for sale to those who are newly eligible, as defined in 14VAC5-170-87, on or after January 1, 2020.

Note that the numeric figures in the following charts, including out-of-pocket limits and deductible amounts, are current as of January 1, 2020, and are subject to change.

Basic Benefits: • 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. Shaded plans shown below represent those offered by Thrivent.

A B C D F F* G Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance





Skilled Nursing Facility Coinsurance




Part A Deductible Part A Deductible Part A Deductible 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

*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 $2340 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2340. 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.

TF34726VA N7-19 page 2 Rev. 5-2020

Outline of Medicare Supplement Coverage Cover page 2 of 2

Benefit Chart of Medicare Supplement Plans Sold with Effective Dates on or after June 1, 2010

Plans A, F, G, N 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.

Plans C, F, and high deductible F are no longer available for sale to those who are newly eligible, as defined in 14VAC5-170-87, on or after January 1, 2020.

Note that the numeric figures in the following charts, including out-of-pocket limits and deductible amounts, are current as of January 1, 2020, and are subject to change.

Basic Benefits: • 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. Shaded plans shown below represent those offered by Thrivent.

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

50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance



50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Foreign Travel Emergency Foreign Travel Emergency Out-of-pocket limit $5880; paid at 100% after limit reached

Out-of-pocket limit $2940; paid at 100% after limit reached

TF34726VA N7-19 page 3 Rev. 5-2020

PREMIUM INFORMATION We, Thrivent Financial for Lutherans, can only raise your premium if we raise the premium for all policies like yours in this Commonwealth. Because your premium is based on attained age, your renewal premium will increase due to age; it will increase on or after the contract anniversary.

NOTE: While the cost of this policy at your present age may be lower than the cost of Medicare Supplement coverage that is based on issue age or is community rated, it is important to compare the potential cost of these policies over the life of the coverage. Premiums for other Medicare Supplement policies that are issue age or community rated do not increase due to changes in your age.

HOUSEHOLD PREMIUM DISCOUNT If for the past year you resided with at least one, but no more than three, other adults who are age 50 or older, you will be eligible for a household premium discount. The discounted premium will be priced 7% lower than the rates illustrated. Your contract’s household premium discount will be removed if the other adult no longer resides with you (other than in the case of his or her death).

DISCLOSURES Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY This is only an outline describing your 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 your insurance company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Thrivent Financial for Lutherans, PO Box 14008, Clearwater, FL 33766-4008. 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 Thrivent 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 and You” for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

TF34726VA N7-19 page 4 Rev. 5-2020

Outline of Medicare Supplement Coverage

Benefit Chart of Medicare Supplement Plans sold on or after January 1, 2020 This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F. Note: A means 100% of the benefit is paid. Shaded plans shown below represent those offered by Thrivent.

Benefits Plans Available to All Applicants

Medicare first eligible

before 2020 only A B D G G1 K L M N C F F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment 50% 75%

copays apply3

Blood (first three pints) 50% 75% Part A hospice care coinsurance or copayment 50% 75% Skilled nursing facility coinsurance 50% 75% Medicare Part A deductible 50% 75% 50% Medicare Part B deductible Medicare Part B excess charges Foreign travel emergency (up to plan limits) Out-of-pocket limit in 20202 $58802 $29402

1Plans F and G also have a high deductible option which require first paying a plan deductible of $2340 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

TF34726VA N7-19 page 5 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – NONSMOKER For ZIP codes starting with: 226-231, 238-246 MALE ATTAINED

AGE FEMALE

Plan A Plan F^ Plan G Plan N Plan A Plan F^ Plan G Plan N 113.52 147.68 116.62 86.96 65 98.71 128.41 101.41 75.62 113.52 147.68 116.62 86.96 66 98.71 128.41 101.41 75.62 113.52 147.68 116.62 86.96 67 98.71 128.41 101.41 75.62 118.35 153.50 121.80 90.75 68 102.92 133.48 105.91 78.92 123.10 159.47 127.10 94.56 69 107.05 138.67 110.52 82.23 127.70 165.03 132.03 98.14 70 111.04 143.50 114.81 85.34 131.52 170.40 136.81 101.74 71 114.36 148.18 118.96 88.47 135.34 175.78 141.58 105.34 72 117.69 152.85 123.12 91.60 139.16 181.16 146.36 108.94 73 121.01 157.53 127.27 94.73 142.98 186.53 151.13 112.53 74 124.33 162.20 131.42 97.86 146.80 191.91 155.91 116.13 75 127.65 166.87 135.57 100.98 150.37 197.89 161.06 120.16 76 130.76 172.08 140.05 104.49 154.01 203.98 166.31 124.27 77 133.92 177.37 144.62 108.06 157.86 210.39 171.82 128.57 78 137.27 182.94 149.41 111.80 161.78 216.92 177.44 132.97 79 140.68 188.62 154.30 115.62 165.93 223.80 183.36 137.58 80 144.29 194.61 159.44 119.64 169.54 230.76 189.34 142.43 81 147.42 200.66 164.65 123.86 173.37 238.11 195.65 147.53 82 150.76 207.05 170.13 128.29 177.29 245.61 202.09 152.75 83 154.16 213.58 175.73 132.82 181.27 253.28 208.68 158.08 84 157.63 220.24 181.46 137.46 185.34 261.11 215.41 163.53 85 161.16 227.06 187.31 142.20 189.65 269.24 222.31 169.08 86 164.91 234.12 193.31 147.03 194.05 277.57 229.39 174.79 87 168.74 241.37 199.47 151.99 198.56 286.13 236.67 180.65 88 172.66 248.81 205.80 157.08 202.97 294.62 243.89 186.48 89 176.49 256.19 212.08 162.16 207.27 303.03 251.06 192.28 90 180.23 263.50 218.31 167.20 210.37 310.00 257.00 197.18 91 182.93 269.57 223.48 171.46 213.53 317.12 263.06 202.19 92 185.68 275.75 228.75 175.82 216.31 323.73 268.71 206.88 93 188.09 281.50 233.66 179.90 219.12 330.45 274.46 211.66 94 190.54 287.35 238.66 184.06 221.96 337.29 280.30 216.53 95 193.01 293.29 243.74 188.29 226.62 344.37 286.19 221.08 96 197.07 299.45 248.86 192.24 231.38 351.61 292.20 225.72 97 201.20 305.74 254.08 196.28 236.24 358.99 298.33 230.46 98 205.43 312.16 259.42 200.40 241.20 366.53 304.60 235.30 99 209.74 318.72 264.87 204.61

To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively. The rates above do not include a one-time contract fee of $25 or a Household Premium Discount. ^Only applicants first eligible for Medicare before January 1, 2020, may purchase Plan F. Rates effective 5-2020

TF34726VA N7-19 page 6 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – SMOKER For ZIP codes starting with: 226-231, 238-246 MALE ATTAINED

AGE FEMALE



TF34726VA N7-19 page 7 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – NONSMOKER For ZIP codes starting with: 232-236 MALE ATTAINED

AGE FEMALE



TF34726VA N7-19 page 8 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – SMOKER For ZIP codes starting with: 232-236 MALE ATTAINED

AGE FEMALE



TF34726VA N7-19 page 9 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – NONSMOKER For ZIP codes starting with: 201, 205, 220-225, 237 MALE ATTAINED

AGE FEMALE



TF34726VA N7-19 page 10 Rev. 5-2020

Thrivent – Monthly $ Premium Rates: Standard Plans – SMOKER For ZIP codes starting with: 201, 205, 220-225, 237 MALE ATTAINED

AGE FEMALE



TF34726VA N7-19 page 11 Rev. 5-2020

PLAN A

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*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.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies

First 60 days All but $1408 $0 $1408 (Part A deductible) 61st through 90th day All but $352 a day $352 a day $0 91st day and after:

- While using 60 lifetime reserve days - Once lifetime reserve days are used:

- Additional 365 days - Beyond the additional 365 days

All but $704 a day $0 $0

$704 a day 100% of Medicare eligible expenses $0

$0 $0** All costs

SKILLED NURSING FACILITY CARE* You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0 21st through 100th day All but $176 a day $0 Up to $176 a day 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance $0

(continued) **NOTICE: 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 for 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.

TF34726VA N7-19 page 12 Rev. 5-2020

PLAN A MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR

*Once you have been billed $198 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES— IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $198 of Medicare Approved Amounts* $0 $0 $198 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs

BLOOD First 3 pints $0 All costs $0 Next $198 of Medicare Approved Amounts* $0 $0 $198 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE— MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies

100% $0 $0

Durable medical equipment First $198 of Medicare Approved Amounts* Remainder of Medicare Approved Amounts

$0 80%

$0 20%

$198 (Part B deductible) $0

Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People with Medicare.

TF34726VA N7-19 page 13 Rev. 5-2020

PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD



First 60 days All but $1408 $1408 (Part A deductible) $0 61st through 90th day All but $352 a day $352 a day $0 91st day and after:





$0 $0** All costs


First 20 days All approved amounts $0 $0 21st through 100th day All but $176 a day Up to $176 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness




TF34726VA N7-19 page 14 Rev. 5-2020

PLAN F MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR



First $198 of Medicare Approved Amounts* $0 $198 (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

100%

$0

BLOOD First 3 pints $0 All costs $0 Next $198 of Medicare Approved Amounts* $0 $198 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES— TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B



100% $0 $0


$0 80%

$198 (Part B deductible) 20%

$0 $0

(continued)

TF34726VA N7-19 page 15 Rev. 5-2020

PLAN F OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL NOT COVERED BY 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 $250 Remainder of charges $0 80% to a lifetime maximum benefit of

$50,000 20% and amounts over the $50,000 lifetime maximum


TF34726VA N7-19 page 16 Rev. 5-2020

PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD








$0 $0** All costs






TF34726VA N7-19 page 17 Rev. 5-2020

PLAN G MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR



First $198 of Medicare Approved Amounts* $0 $0 $198 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

100%

$0


100%

$0

$0

PARTS A & B



100% $0 $0


$0 80%

$0 20%


(continued)

TF34726VA N7-19 page 18 Rev. 5-2020

PLAN G OTHER BENEFITS – NOT COVERED BY MEDICARE





TF34726VA N7-19 page 19 Rev. 5-2020

PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD








$0 $0** All costs






TF34726VA N7-19 page 20 Rev. 5-2020

PLAN N MEDICARE (PART B) – MEDICAL EXPENSES – PER CALENDAR YEAR



First $198 of Medicare Approved Amounts* $0 $0 $198 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Balance, other than up to $20 per

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

PART B EXCESS CHARGES (Above Medicare Approved Amounts)

$0

$0

All costs


100%

$0

$0

(continued)

TF34726VA N7-19 page 21 Rev. 5-2020

PLAN N PARTS A & B



100% $0 $0


$0 80%

$0 20%


OTHER BENEFITS – NOT COVERED BY MEDICARE





Outline of Medicare Supplement Coverage · 2020. 5. 5. · Benefit Chart of Medicare Supplement...

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