thp insurance company, inc. 2016 medicare supplement · medicare supplement monthly premium rates...

It’s not about health insurance.

It’s about peace of mind.

2016 Medicare SupplementTHP Insurance Company, Inc.

Ohio and West Virginia

1.877.847.7915

FORM# OH: OHTHP-83WV: WVTHP-53

Contents I. Outline of Medicare Supplement Plan CoverageII. Premium InformationIII. Benefit Plan Summaries

I. Outline of Medicare Supplement Plan Coverage

OUTLINE OF MEDICARE SUPPLEMENT PLAN COVERAGETHP Insurance Company (THP)

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

This is only an outline describing your policy’s most important features. The policy is your health insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your health insurance company, THP.

READ YOUR POLICY CAREFULLY

If you find that you are not satisfied with your policy, you may return it to:

THP Insurance Company 52160 National Road East St. Clairsville, OH 43950-9365

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.

RIGHT TO RETURN POLICY

This policy may not fully cover all of your medical costs.Neither THP Insurance Company 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.

NOTICE

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 health coverage and refuse to pay any claims if you leave out or falsify important medical information.Review your application carefully before you sign it. Be certain that all information has been properly recorded.

COMPLETE ANSWERS ARE VERY IMPORTANT

THP Insurance Company 100 Lillian Gish Blvd. P.O. Box 4816 Massillon, OH 44648-4816

or

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.

POLICY REPLACEMENT

Ohio and West Virginia Outline THP Medicare Supplement Insurance CoverageBenefit plans A, C, D, F, High Deductible F, G, and N are available (see below)These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available “A.” Some plans may not be available in your state.See Outline of Coverage sections for details about all plans.Basic Benefits: All plansHospitalization: Medicare Part A coinsurance plus coverage for 365 additional days after Medicare benefits endMedical 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 copaymentsBlood: First three (3) pints of blood each yearHospice: Part A coinsurance

Basic,including

100% Part B coinsurance

Part B Deductible

Part B Deductible

Out-of-Pocket limit $4940;

paid at 100% after limit reached

Out-of-Pocket limit $2470;

paid at 100% after limit reached

Part B Excess (100%)

Part B Excess (100%)

Hospitalization and preventive

care paid at 100%; other

basic benefits paid at 50%

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Basic, including 100% Part B coinsurance,

except up to $20 copayment for

office visit, and up to $50 copayment

for ER

Plan A Plan B Plan C Plan D Plan F Plan G Plan K Plan L Plan M Plan N

Skilled Nursing Facility

coinsurance


coinsurance

75% Skilled Nursing Facility

coinsurance

50% Skilled Nursing Facility

coinsurance


coinsurance


coinsurance


coinsurance


coinsurancePart A

DeductiblePart A

Deductible50% Part A Deductible

75% Part A Deductible

50% Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

F*Basic,

including 100% Part B coinsurance

Basic,including


Basic,including


Basic,including


Basic,including


Hospitalization and preventive

care paid at 100%; other

basic benefits paid at 75%

Basic,including


*Plan F also offers a high-deductible plan. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2180. 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 plans’ separate foreign travel emergency deductible.

Columns in gray are the Medicare Supplement Plans not available from THP Insurance Company.

II. Premium Information

Medicare Supplement Monthly Premium Rates Region 1*We, THP Insurance Company can only raise your premium if we raise the premium for all policies in this state. Your premium is determined upon your gender and attained age. Your premium will change each year based upon your attained age on the date of your plan renewal, January 1.

After the first one month’s payments, the term of this coverage is for one month if you have chosen monthly premium payments. If you prepay this coverage on a quarterly, semi-annual or annual basis, the term of the coverage will be the period prepaid. The policy renews automatically, subject to the right of THP Insurance Company to change premium charges.

MALE FEMALE

Plan A Plan C Plan D Plan F Plan FHD Plan G Plan N Plan A Plan C Plan D Plan F Plan

FHD Plan G Plan N

65 $89.53 $127.94 $114.41 $128.02 $52.47 $114.48 $102.85 $94.76 $131.51 $117.06 $131.59 $53.85 $117.14 $104.7766 94.02 135.43 121.20 135.51 55.36 121.28 109.03 97.89 137.51 122.58 137.59 56.16 122.67 109.8767 98.51 142.92 127.98 143.00 58.25 128.07 115.21 101.03 143.50 128.10 143.59 58.48 128.19 114.9768 103.00 150.40 134.77 150.49 61.14 134.86 121.39 104.17 149.50 133.63 149.59 60.79 133.72 120.0769 107.50 157.89 141.56 157.99 64.03 141.65 127.57 107.31 155.50 139.15 155.59 63.11 139.24 125.1870 111.99 165.38 148.35 165.48 66.92 148.44 133.75 110.45 161.49 144.67 161.59 65.42 144.77 130.2871 116.48 172.87 155.14 172.97 69.82 155.24 139.93 113.59 167.49 150.20 167.59 67.74 150.30 135.3872 120.97 180.36 161.92 180.46 72.71 162.03 146.11 116.72 173.49 155.72 173.59 70.05 155.82 140.4873 125.19 188.78 169.72 188.89 75.96 169.83 153.34 119.39 180.23 162.10 180.34 72.66 162.20 146.5174 129.41 197.21 177.52 197.32 79.21 177.63 160.58 122.06 186.98 168.48 187.09 75.26 168.58 152.5475 133.63 205.63 185.32 205.75 82.47 185.43 167.81 124.73 193.73 174.86 193.84 77.87 174.96 158.5676 137.84 214.06 193.11 214.18 85.72 193.23 175.04 127.40 200.48 181.23 200.59 80.47 181.34 164.5977 142.06 222.49 200.91 222.61 88.97 201.03 182.27 130.07 207.22 187.61 207.33 83.08 187.72 170.6278 145.00 231.15 209.19 231.27 92.31 209.32 190.17 132.06 214.99 195.16 215.10 86.07 195.27 177.9279 147.95 239.81 217.47 239.94 95.66 217.60 198.07 134.05 222.75 202.71 222.87 89.07 202.82 185.2180 150.89 248.47 225.75 248.60 99.00 225.88 205.97 136.04 230.52 210.25 230.63 92.07 210.37 192.5181 153.83 257.13 234.03 257.26 102.34 234.16 213.87 138.03 238.28 217.80 238.40 95.06 217.92 199.8182 156.78 265.80 242.31 265.93 105.69 242.44 221.77 140.01 246.05 225.35 246.17 98.06 225.46 207.1183 159.23 283.30 259.71 283.43 112.44 259.84 238.90 140.38 261.98 241.54 262.10 104.21 241.66 223.3284 161.67 300.80 277.11 300.94 119.20 277.24 256.02 140.75 277.92 257.74 278.03 110.36 257.85 239.5385+ 164.12 318.31 294.51 318.44 125.95 294.64 273.15 141.12 293.86 273.93 293.97 116.51 274.04 255.74

* Region 1: OH counties: Portage, Summit

AGE



MALE FEMALE


FHD Plan G Plan N

65 $89.58 $126.57 $113.05 $126.66 $51.94 $113.13 $101.08 $94.95 $130.45 $116.00 $130.54 $53.43 $116.09 $103.2666 94.04 133.90 119.67 133.98 54.76 119.76 107.07 98.04 136.26 121.34 136.35 55.68 121.43 108.1767 98.50 141.22 126.30 141.31 57.59 126.39 113.07 101.13 142.07 126.67 142.16 57.92 126.77 113.0768 102.96 148.54 132.92 148.64 60.42 133.02 119.07 104.22 147.87 132.01 147.97 60.16 132.10 117.9769 107.42 155.87 139.55 155.97 63.25 139.65 125.06 107.31 153.68 137.34 153.78 62.40 137.44 122.8770 111.88 163.19 146.17 163.30 66.07 146.27 131.06 110.40 159.49 142.68 159.59 64.64 142.78 127.7771 116.34 170.52 152.79 170.62 68.90 152.90 137.06 113.49 165.30 148.01 165.40 66.89 148.12 132.6872 120.80 177.84 159.42 177.95 71.73 159.53 143.05 116.57 171.10 153.35 171.21 69.13 153.46 137.5873 124.94 185.98 166.93 186.09 74.87 167.04 149.98 119.14 177.53 159.41 177.64 71.61 159.52 143.2874 129.08 194.11 174.44 194.23 78.01 174.56 156.91 121.71 183.96 165.47 184.07 74.09 165.58 148.9975 133.22 202.25 181.95 202.38 81.15 182.07 163.84 124.28 190.39 171.53 190.50 76.57 171.65 154.6976 137.35 210.39 189.46 210.52 84.30 189.59 170.77 126.85 196.82 177.59 196.93 79.05 177.71 160.3977 141.49 218.53 196.97 218.66 87.44 197.10 177.70 129.42 203.25 183.66 203.37 81.54 183.77 166.1078 144.28 226.72 204.78 226.85 90.60 204.92 185.13 131.23 210.51 190.70 210.63 84.34 190.82 172.9079 147.07 234.91 212.60 235.05 93.76 212.73 192.56 133.05 217.77 197.75 217.90 87.14 197.87 179.7080 149.86 243.10 220.41 243.24 96.92 220.55 199.99 134.86 225.04 204.80 225.16 89.95 204.92 186.5081 152.65 251.30 228.22 251.44 100.09 228.36 207.41 136.68 232.30 211.85 232.43 92.75 211.97 193.3082 155.44 259.49 236.04 259.63 103.25 236.18 214.84 138.50 239.57 218.90 239.69 95.55 219.02 200.1083 157.39 275.61 252.06 275.75 109.47 252.20 230.61 138.31 254.01 233.61 254.14 101.13 233.73 214.8684 159.34 291.73 268.08 291.88 115.69 268.23 246.38 138.13 268.46 248.32 268.58 106.70 248.44 229.6385+ 161.29 307.86 284.11 308.00 121.91 284.25 262.16 137.95 282.91 263.04 283.03 112.28 263.15 244.39

* Region 2: OH counties: Carroll, Stark

AGE



MALE FEMALE


FHD Plan G Plan N

65 $97.82 $138.30 $124.72 $138.38 $56.48 $124.80 $111.99 $103.64 $142.26 $127.76 $142.35 $58.01 $127.84 $114.2266 102.74 146.40 132.11 146.49 59.61 132.20 118.72 107.06 148.73 133.75 148.82 60.51 133.84 119.7667 107.65 154.50 139.51 154.59 62.74 139.60 125.45 110.48 155.20 139.75 155.30 63.01 139.84 125.2968 112.57 162.60 146.91 162.69 65.86 147.00 132.18 113.90 161.68 145.74 161.77 65.51 145.84 130.8269 117.48 170.70 154.30 170.80 68.99 154.40 138.90 117.32 168.15 151.74 168.25 68.01 151.84 136.3670 122.40 178.80 161.70 178.90 72.12 161.80 145.63 120.74 174.62 157.74 174.72 70.50 157.84 141.8971 127.32 186.90 169.10 187.01 75.24 169.20 152.36 124.16 181.09 163.73 181.20 73.00 163.83 147.4272 132.23 195.00 176.49 195.11 78.37 176.60 159.09 127.58 187.56 169.73 187.67 75.50 169.83 152.9673 136.82 204.09 184.95 204.20 81.88 185.06 166.92 130.45 194.82 176.61 194.93 78.30 176.72 159.4574 141.41 213.17 193.41 213.29 85.39 193.52 174.76 133.33 202.07 183.50 202.18 81.10 183.61 165.9575 146.00 222.26 201.86 222.38 88.90 201.98 182.60 136.21 209.33 190.38 209.44 83.90 190.49 172.4576 150.59 231.35 210.32 231.48 92.41 210.44 190.43 139.08 216.58 197.26 216.70 86.70 197.38 178.9577 155.18 240.44 218.77 240.57 95.91 218.90 198.27 141.96 223.84 204.15 223.96 89.50 204.26 185.4578 158.32 249.74 227.69 249.87 99.50 227.82 206.76 144.05 232.16 212.24 232.27 92.71 212.36 193.2879 161.47 259.04 236.60 259.17 103.09 236.74 215.26 146.14 240.47 220.34 240.59 95.92 220.46 201.1080 164.62 268.33 245.52 268.47 106.68 245.65 223.76 148.24 248.79 228.43 248.91 99.13 228.55 208.9281 167.77 277.63 254.43 277.77 110.27 254.57 232.25 150.33 257.10 236.53 257.22 102.34 236.65 216.7482 170.92 286.93 263.34 287.07 113.86 263.48 240.75 152.42 265.42 244.62 265.54 105.55 244.74 224.5783 173.34 305.61 281.92 305.75 121.07 282.06 259.03 152.53 282.37 261.82 282.49 112.09 261.95 241.8084 175.76 324.30 300.49 324.44 128.28 300.63 277.31 152.64 299.32 279.03 299.44 118.63 279.15 259.0385+ 178.18 342.98 319.06 343.12 135.49 319.20 295.59 152.74 316.27 296.23 316.39 125.17 296.35 276.27

* Region 3: OH counties: Medina

AGE



MALE FEMALE


FHD Plan G Plan N

65 $103.53 $145.42 $131.80 $145.52 $59.28 $131.90 $117.71 $109.62 $149.52 $134.98 $149.62 $60.86 $135.08 $119.9966 108.77 153.97 139.65 154.07 62.58 139.74 124.81 113.28 156.36 141.34 156.47 63.50 141.45 125.8467 114.01 162.52 147.49 162.62 65.88 147.59 131.91 116.95 163.20 147.71 163.31 66.14 147.81 131.6968 119.25 171.06 155.33 171.17 69.18 155.44 139.01 120.61 170.04 154.07 170.16 68.78 154.18 137.5469 124.49 179.61 163.17 179.73 72.48 163.29 146.12 124.27 176.89 160.44 177.00 71.42 160.55 143.3970 129.73 188.16 171.02 188.28 75.78 171.13 153.22 127.93 183.73 166.80 183.85 74.07 166.92 149.2571 134.97 196.71 178.86 196.83 79.08 178.98 160.32 131.59 190.57 173.16 190.69 76.71 173.28 155.1072 140.21 205.25 186.70 205.38 82.38 186.83 167.42 135.26 197.41 179.53 197.53 79.35 179.65 160.9573 145.13 214.87 195.68 215.00 86.09 195.81 175.71 138.37 205.10 186.85 205.23 82.32 186.97 167.8574 150.06 224.48 204.66 224.62 89.80 204.79 184.01 141.49 212.80 194.17 212.93 85.29 194.29 174.7475 154.98 234.09 213.63 234.23 93.51 213.77 192.30 144.61 220.49 201.49 220.62 88.26 201.62 181.6476 159.90 243.71 222.61 243.85 97.22 222.76 200.59 147.72 228.18 208.81 228.32 91.23 208.94 188.5377 164.82 253.32 231.59 253.47 100.93 231.74 208.88 150.84 235.88 216.13 236.01 94.20 216.26 195.4378 168.26 263.19 241.08 263.34 104.74 241.23 217.91 153.17 244.72 224.75 244.86 97.61 224.89 203.7579 171.70 273.06 250.56 273.22 108.55 250.71 226.94 155.49 253.57 233.37 253.71 101.02 233.51 212.0880 175.14 282.94 260.05 283.09 112.36 260.20 235.96 157.82 262.42 241.99 262.56 104.44 242.13 220.4181 178.58 292.81 269.53 292.97 116.17 269.69 244.99 160.15 271.26 250.62 271.40 107.85 250.76 228.7382 182.02 302.68 279.02 302.84 119.98 279.18 254.01 162.48 280.11 259.24 280.25 111.27 259.38 237.0683 184.89 322.61 298.83 322.77 127.68 298.99 273.51 162.93 298.24 277.62 298.38 118.26 277.76 255.4884 187.77 342.54 318.64 342.70 135.37 318.80 293.02 163.38 316.37 296.00 316.51 125.26 296.14 273.9185+ 190.64 362.47 338.45 362.63 143.06 338.62 312.52 163.83 334.51 314.38 334.64 132.25 314.51 292.33

* Region 4: OH counties: Jefferson; WV counties: Brooke, Hancock

AGE



MALE FEMALE


FHD Plan G Plan N

65 $92.80 $129.75 $116.20 $129.82 $53.21 $116.28 $104.03 $98.34 $133.82 $119.35 $133.90 $54.78 $119.44 $106.4066 97.43 137.23 122.99 137.31 56.10 123.07 110.18 101.56 139.74 124.80 139.82 57.07 124.89 111.4167 102.07 144.72 129.78 144.80 58.99 129.86 116.33 104.78 145.66 130.25 145.75 59.36 130.34 116.4268 106.71 152.20 136.56 152.29 61.88 136.65 122.48 108.00 151.58 135.70 151.67 61.64 135.79 121.4369 111.35 159.69 143.35 159.79 64.77 143.44 128.63 111.22 157.50 141.14 157.59 63.93 141.24 126.4370 115.99 167.18 150.14 167.28 67.66 150.23 134.78 114.44 163.42 146.59 163.52 66.21 146.69 131.4471 120.63 174.66 156.92 174.77 70.55 157.02 140.92 117.66 169.34 152.04 169.44 68.50 152.14 136.4572 125.27 182.15 163.71 182.26 73.44 163.81 147.07 120.87 175.26 157.48 175.36 70.78 157.59 141.4673 129.58 190.44 171.37 190.55 76.64 171.48 154.14 123.56 181.78 163.64 181.89 73.30 163.74 147.2574 133.90 198.73 179.03 198.84 79.84 179.14 161.22 126.25 188.30 169.79 188.41 75.82 169.90 153.0475 138.21 207.01 186.69 207.13 83.04 186.81 168.29 128.94 194.83 175.95 194.94 78.34 176.06 158.8376 142.53 215.30 194.35 215.42 86.24 194.47 175.36 131.63 201.35 182.10 201.46 80.85 182.21 164.6277 146.84 223.59 202.01 223.72 89.44 202.13 182.43 134.32 207.87 188.26 207.98 83.37 188.37 170.4178 149.77 231.88 209.92 232.01 92.64 210.05 189.95 136.25 215.20 195.37 215.31 86.20 195.48 177.2879 152.70 240.18 217.84 240.31 95.84 217.97 197.48 138.17 222.53 202.48 222.65 89.03 202.60 184.1480 155.64 248.47 225.75 248.60 99.05 225.88 205.00 140.10 229.86 209.60 229.98 91.86 209.72 191.0081 158.57 256.77 233.67 256.90 102.25 233.80 212.52 142.02 237.19 216.71 237.31 94.69 216.83 197.8682 161.50 265.06 241.58 265.20 105.45 241.72 220.04 143.95 244.52 223.83 244.64 97.52 223.95 204.7383 163.64 281.26 257.68 281.39 111.70 257.81 235.89 143.89 258.96 238.53 259.08 103.09 238.65 219.4984 165.78 297.45 273.77 297.58 117.95 273.91 251.73 143.82 273.40 253.24 273.52 108.66 253.36 234.2585+ 167.92 313.64 289.87 313.78 124.20 290.00 267.57 143.76 287.85 267.95 287.96 114.23 268.06 249.01

* Region 5: OH counties: Belmont; WV counties: Marshall, Ohio

AGE



MALE FEMALE


FHD Plan G Plan N

65 $98.00 $138.40 $124.82 $138.49 $56.54 $124.91 $111.40 $103.73 $142.28 $127.78 $142.38 $58.04 $127.87 $113.5066 102.95 146.53 132.24 146.62 59.67 132.33 118.12 107.19 148.79 133.81 148.89 60.55 133.90 119.0567 107.90 154.65 139.66 154.75 62.81 139.76 124.83 110.66 155.29 139.84 155.40 63.06 139.94 124.5968 112.85 162.78 147.08 162.88 65.95 147.19 131.55 114.12 161.80 145.86 161.90 65.57 145.97 130.1369 117.80 170.90 154.50 171.01 69.08 154.61 138.27 117.58 168.30 151.89 168.41 68.08 152.00 135.6770 122.75 179.02 161.92 179.14 72.22 162.04 144.98 121.04 174.81 157.92 174.92 70.59 158.03 141.2171 127.70 187.15 169.35 187.27 75.36 169.46 151.70 124.51 181.31 163.95 181.43 73.11 164.07 146.7672 132.65 195.27 176.77 195.40 78.50 176.89 158.42 127.97 187.82 169.98 187.94 75.62 170.10 152.3073 137.31 204.41 185.28 204.54 82.02 185.40 166.27 130.92 195.14 176.93 195.26 78.44 177.05 158.8474 141.96 213.56 193.78 213.69 85.55 193.92 174.13 133.88 202.46 183.88 202.58 81.27 184.00 165.3975 146.62 222.70 202.29 222.83 89.08 202.43 181.98 136.84 209.78 190.82 209.90 84.09 190.95 171.9376 151.27 231.84 210.80 231.98 92.61 210.94 189.84 139.79 217.09 197.77 217.22 86.92 197.90 178.4777 155.93 240.98 219.31 241.12 96.14 219.45 197.70 142.75 224.41 204.72 224.54 89.74 204.85 185.0278 159.20 250.37 228.32 250.52 99.77 228.47 206.27 144.96 232.83 212.92 232.97 92.99 213.05 192.9379 162.46 259.77 237.33 259.92 103.39 237.48 214.84 147.18 241.26 221.12 241.39 96.24 221.25 200.8580 165.73 269.16 246.34 269.31 107.02 246.49 223.41 149.40 249.68 229.32 249.81 99.49 229.45 208.7781 169.00 278.56 255.35 278.71 110.64 255.50 231.99 151.62 258.10 237.52 258.23 102.74 237.65 216.6882 172.26 287.95 264.36 288.11 114.27 264.51 240.56 153.84 266.52 245.72 266.66 105.99 245.85 224.6083 175.04 306.93 283.23 307.09 121.60 283.38 259.13 154.34 283.80 263.25 283.93 112.66 263.38 242.1784 177.82 325.92 302.10 326.07 128.92 302.25 277.71 154.84 301.08 280.78 301.21 119.33 280.91 259.7585+ 180.60 344.90 320.97 345.05 136.25 321.12 296.28 155.34 318.36 298.31 318.49 125.99 298.44 277.32

* Region 6: OH counties: Mahoning, Trumbull

AGE



MALE FEMALE


FHD Plan G Plan N

65 $101.50 $140.02 $126.43 $140.10 $57.17 $126.51 $113.37 $107.63 $144.53 $130.01 $144.62 $58.91 $130.10 $116.1166 106.59 148.10 133.81 148.19 60.29 133.90 120.06 111.16 150.91 135.91 151.00 61.38 136.00 121.5467 111.68 156.19 141.19 156.28 63.41 141.28 126.76 114.68 157.28 141.81 157.37 63.84 141.91 126.9768 116.77 164.27 148.57 164.37 66.53 148.66 133.45 118.21 163.66 147.71 163.75 66.30 147.81 132.4069 121.86 172.35 155.95 172.45 69.65 156.05 140.15 121.73 170.03 153.61 170.13 68.76 153.71 137.8270 126.95 180.44 163.33 180.54 72.78 163.43 146.84 125.26 176.41 159.51 176.51 71.22 159.62 143.2571 132.04 188.52 170.71 188.63 75.90 170.82 153.54 128.78 182.78 165.41 182.89 73.68 165.52 148.6872 137.13 196.60 178.09 196.71 79.02 178.20 160.23 132.31 189.16 171.31 189.27 76.14 171.42 154.1173 141.85 205.52 186.38 205.64 82.46 186.49 167.89 135.24 196.15 177.94 196.26 78.84 178.05 160.3474 146.58 214.44 194.66 214.56 85.90 194.78 175.54 138.17 203.14 184.56 203.25 81.54 184.67 166.5775 151.30 223.36 202.95 223.48 89.35 203.07 183.20 141.10 210.13 191.18 210.25 84.24 191.29 172.8176 156.02 232.27 211.24 232.40 92.79 211.36 190.85 144.03 217.12 197.80 217.24 86.94 197.92 179.0477 160.74 241.19 219.52 241.32 96.23 219.65 198.51 146.96 224.12 204.42 224.24 89.64 204.54 185.2778 163.93 250.07 228.01 250.20 99.66 228.15 206.58 149.03 231.93 212.02 232.05 92.65 212.14 192.6079 167.11 258.94 236.51 259.07 103.08 236.64 214.65 151.10 239.75 219.62 239.87 95.67 219.74 199.9380 170.29 267.81 245.00 267.95 106.51 245.13 222.72 153.18 247.57 227.22 247.69 98.69 227.34 207.2681 173.47 276.68 253.49 276.82 109.93 253.63 230.79 155.25 255.39 234.82 255.51 101.70 234.94 214.5982 176.65 285.56 261.98 285.70 113.36 262.12 238.86 157.32 263.20 242.42 263.33 104.72 242.54 221.9283 178.88 302.75 279.07 302.89 119.99 279.21 255.68 157.11 278.46 257.94 278.58 110.61 258.06 237.5084 181.10 319.94 296.15 320.08 126.62 296.29 272.50 156.90 293.72 273.45 293.84 116.50 273.57 253.0885+ 183.32 337.13 313.24 337.27 133.26 313.38 289.32 156.68 308.98 288.97 309.09 122.38 289.09 268.67

* Region 7: OH counties: Ashland, Columbiana, Coshocton, Guernsey, Harrison, Holmes, Monroe, Muskingum, Noble, Tuscarawas, Washington, Wayne

AGE



MALE FEMALE


FHD Plan G Plan N

65 $96.01 $132.84 $119.28 $133.00 $54.45 $119.44 $106.72 $101.77 $137.14 $122.66 $137.32 $56.11 $122.83 $109.3066 100.82 140.48 126.22 140.64 57.40 126.39 113.00 105.11 143.16 128.21 143.34 58.44 128.39 114.3967 105.63 148.11 133.16 148.29 60.35 133.33 119.28 108.44 149.18 133.75 149.36 60.76 133.94 119.4868 110.44 155.75 140.09 155.94 63.30 140.28 125.56 111.77 155.20 139.30 155.39 63.09 139.49 124.5769 115.24 163.39 147.03 163.59 66.25 147.23 131.84 115.11 161.22 144.84 161.41 65.41 145.04 129.6770 120.05 171.03 153.97 171.23 69.20 154.17 138.13 118.44 167.24 150.39 167.44 67.74 150.59 134.7671 124.86 178.67 160.91 178.88 72.15 161.12 144.41 121.78 173.26 155.93 173.46 70.06 156.14 139.8572 129.67 186.31 167.85 186.53 75.10 168.07 150.69 125.11 179.27 161.48 179.48 72.39 161.69 144.9473 134.13 194.73 175.64 194.95 78.36 175.86 157.87 127.90 185.86 167.70 186.08 74.93 167.91 150.7974 138.60 203.14 183.42 203.38 81.61 183.65 165.05 130.68 192.45 173.92 192.67 77.47 174.14 156.6375 143.07 211.56 191.21 211.80 84.86 191.45 172.23 133.46 199.03 180.10 199.26 80.02 180.36 162.4876 147.54 219.97 199.00 220.22 88.11 199.24 179.41 136.25 205.62 186.36 205.85 82.56 186.58 168.3377 152.01 228.39 206.78 228.65 91.36 207.04 186.59 139.03 212.21 192.57 212.44 85.10 192.80 174.1778 155.04 236.74 214.76 237.00 94.58 215.02 194.16 141.02 219.56 199.71 219.79 87.94 199.94 181.0579 158.08 245.09 222.73 245.36 97.81 222.99 201.73 143.01 226.90 206.84 227.14 90.78 207.07 187.9280 161.11 253.45 230.70 253.71 101.03 230.97 209.30 144.99 234.25 213.97 234.49 93.61 214.21 194.8081 164.14 261.80 238.67 262.07 104.25 238.94 216.87 146.98 241.60 221.10 241.84 96.45 221.34 201.6782 167.17 270.15 246.65 270.43 107.48 246.92 224.45 148.97 248.95 228.23 249.19 99.29 228.47 208.5583 169.36 286.28 262.67 286.55 113.70 262.95 240.22 148.88 263.23 242.78 263.47 104.79 243.02 223.1684 171.56 302.40 278.70 302.68 119.93 278.98 256.00 148.79 277.51 257.33 277.75 110.30 257.56 237.7885+ 173.75 318.53 294.73 318.81 126.15 295.01 271.77 148.69 291.79 271.88 292.02 115.81 272.11 252.39

* Region 8: WV counties: Barbour, Berkeley, Boone, Braxton, Cabell, Calhoun, Clay, Doddridge, Fayette, Gilmer, Grant, Greenbrier, Hardy, Harrison, Jackson, Jefferson, Lewis, Lincoln, Logan, Mason, Marion, McDowell, Mercer, Mineral, Mingo, Monroe, Morgan, Nicholas, Pendleton, Pleasants, Pocahontas, Preston, Putnam, Raleigh, Randolph, Ritchie, Roane, Summers, Taylor, Tucker, Tyler, Upshur, Wayne, Webster, Wetzel, Wirt, Wood, Wyoming

AGE



MALE FEMALE


FHD Plan G Plan N

65 $99.70 $138.60 $125.02 $138.69 $56.61 $125.10 $111.90 $105.47 $142.70 $128.19 $142.79 $58.20 $128.28 $114.2366 104.75 146.69 132.40 146.78 59.74 132.49 118.59 109.02 149.14 134.15 149.23 60.68 134.25 119.7267 109.81 154.77 139.78 154.87 62.86 139.88 125.29 112.57 155.58 140.12 155.67 63.17 140.21 125.2168 114.86 162.86 147.17 162.96 65.98 147.27 131.98 116.11 162.02 146.08 162.12 65.66 146.18 130.7069 119.92 170.95 154.55 171.05 69.10 154.65 138.68 119.66 168.46 152.05 168.56 68.14 152.15 136.1970 124.97 179.03 161.93 179.14 72.22 162.04 145.37 123.21 174.90 158.01 175.00 70.63 158.12 141.6871 130.02 187.12 169.32 187.23 75.35 169.43 152.06 126.76 181.34 163.98 181.45 73.11 164.08 147.1672 135.08 195.21 176.70 195.32 78.47 176.82 158.76 130.30 187.78 169.94 187.89 75.60 170.05 152.6573 139.85 204.24 185.10 204.36 81.96 185.22 166.53 133.35 194.96 176.75 195.07 78.37 176.86 159.0774 144.63 213.28 193.51 213.40 85.44 193.63 174.29 136.41 202.14 183.56 202.25 81.14 183.68 165.4875 149.40 222.31 201.91 222.44 88.93 202.04 182.06 139.46 209.32 190.37 209.44 83.92 190.49 171.9076 154.18 231.34 210.31 231.48 92.42 210.44 189.82 142.51 216.50 197.18 216.62 86.69 197.30 178.3277 158.95 240.38 218.72 240.52 95.91 218.85 197.59 145.56 223.68 203.99 223.80 89.46 204.11 184.7378 162.35 249.56 227.51 249.70 99.45 227.65 205.96 147.89 231.86 211.95 231.98 92.62 212.07 192.4279 165.74 258.74 236.31 258.88 102.99 236.45 214.33 150.22 240.04 219.91 240.16 95.77 220.03 200.1080 169.13 267.92 245.10 268.06 106.54 245.25 222.70 152.55 248.22 227.87 248.35 98.93 227.99 207.7881 172.52 277.10 253.90 277.25 110.08 254.05 231.07 154.89 256.40 235.83 256.53 102.09 235.95 215.4782 175.91 286.28 262.70 286.43 113.63 262.84 239.44 157.22 264.58 243.79 264.71 105.24 243.91 223.1583 178.94 304.56 280.87 304.71 120.68 281.02 257.33 157.95 281.08 260.54 281.21 111.61 260.67 239.9684 181.98 322.85 299.05 323.00 127.74 299.19 275.22 158.69 297.58 277.30 297.71 117.98 277.43 256.7685+ 185.02 341.13 317.22 341.28 134.79 317.37 293.11 159.42 314.09 294.06 314.21 124.34 294.18 273.56

* Region 9: OH counties: Adams, Allen, Ashtabula, Athens, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Crawford, Cuyahoga, Darke, Defiance, Delaware, Erie, Fairfield, Fayette, Franklin, Fulton, Gallia, Geauga, Greene, Hamilton, Hancock, Hardin, Henry, Highland, Hocking, Huron, Jackson, Knox, Lake, Lawrence, Licking, Logan, Lorain, Lucas, Madison, Marion, Meigs, Mercer, Miami, Montgomery, Morgan, Morrow, Ottawa, Paulding, Perry, Pickaway, Pike, Preble, Putnam, Richland, Ross, Sandusky, Scioto, Seneca, Shelby, Union, Van Wert, Vinton, Warren, Williams, Wood, Wyandot

AGE



MALE FEMALE


FHD Plan G Plan N

65 $91.34 $126.37 $113.48 $126.53 $51.80 $113.63 $101.53 $96.82 $130.47 $116.70 $130.63 $53.38 $116.86 $103.9866 95.92 133.64 120.08 133.80 54.61 120.24 107.50 99.99 136.20 121.97 136.37 55.60 122.14 108.8367 100.49 140.91 126.68 141.08 57.41 126.85 113.48 103.16 141.92 127.25 142.10 57.81 127.42 113.6768 105.06 148.18 133.28 148.35 60.22 133.45 119.45 106.34 147.65 132.52 147.83 60.02 132.70 118.5169 109.64 155.44 139.88 155.63 63.03 140.06 125.43 109.51 153.37 137.80 153.56 62.23 137.98 123.3670 114.21 162.71 146.48 162.90 65.84 146.67 131.41 112.68 159.10 143.07 159.29 64.44 143.26 128.2071 118.78 169.98 153.08 170.18 68.64 153.28 137.38 115.85 164.83 148.35 165.02 66.65 148.54 133.0572 123.36 177.25 159.68 177.45 71.45 159.89 143.36 119.02 170.55 153.62 170.75 68.86 153.82 137.8973 127.61 185.25 167.09 185.47 74.54 167.30 150.19 121.67 176.82 159.54 177.02 71.28 159.74 143.4574 131.86 193.26 174.50 193.48 77.64 174.72 157.02 124.32 183.08 165.46 183.29 73.70 165.66 149.0175 136.11 201.26 181.91 201.49 80.73 182.13 163.85 126.97 189.35 171.37 189.56 76.12 171.58 154.5876 140.37 209.27 189.32 209.51 83.82 189.55 170.68 129.62 195.62 177.29 195.83 78.54 177.50 160.1477 144.62 217.28 196.72 217.52 86.91 196.97 177.51 132.27 201.88 183.20 202.10 80.96 183.42 165.7078 147.50 225.22 204.31 225.47 89.98 204.55 184.72 134.16 208.87 189.99 209.10 83.66 190.21 172.2479 150.38 233.17 211.89 233.42 93.05 212.14 191.92 136.05 215.86 196.77 216.09 86.36 197.00 178.7880 153.27 241.12 219.48 241.37 96.11 219.73 199.12 137.94 222.86 203.56 223.08 89.06 203.78 185.3281 156.15 249.06 227.06 249.32 99.18 227.32 206.32 139.83 229.85 210.34 230.07 91.76 210.57 191.8682 159.04 257.01 234.65 257.27 102.25 234.91 213.53 141.72 236.84 217.13 237.07 94.45 217.36 198.4083 161.12 272.35 249.89 272.61 108.17 250.16 228.53 141.63 250.42 230.97 250.65 99.70 231.19 212.3184 163.21 287.69 265.14 287.95 114.09 265.40 243.54 141.55 264.01 244.81 264.23 104.94 245.03 226.2185+ 165.30 303.03 280.39 303.30 120.01 280.65 258.55 141.46 277.60 258.65 277.82 110.18 258.87 240.11

* Region 10: WV counties: Kanawha

AGE



MALE FEMALE


FHD Plan G Plan N

65 $90.53 $125.25 $112.47 $125.41 $51.34 $112.62 $100.63 $95.96 $129.32 $115.66 $129.48 $52.91 $115.82 $103.0666 95.07 132.46 119.01 132.62 54.12 119.17 106.55 99.11 134.99 120.89 135.16 55.10 121.06 107.8667 99.60 139.66 125.56 139.83 56.91 125.72 112.47 102.25 140.67 126.12 140.84 57.30 126.29 112.6668 104.13 146.86 132.10 147.04 59.69 132.27 118.40 105.39 146.34 131.35 146.52 59.49 131.52 117.4669 108.66 154.07 138.64 154.25 62.47 138.82 124.32 108.54 152.02 136.58 152.20 61.68 136.76 122.2770 113.20 161.27 145.18 161.46 65.25 145.37 130.24 111.68 157.69 141.80 157.88 63.87 141.99 127.0771 117.73 168.47 151.73 168.67 68.04 151.92 136.16 114.83 163.37 147.03 163.56 66.06 147.23 131.8772 122.26 175.68 158.27 175.88 70.82 158.47 142.09 117.97 169.04 152.26 169.24 68.25 152.46 136.6773 126.48 183.61 165.61 183.82 73.88 165.82 148.86 120.60 175.25 158.13 175.46 70.65 158.33 142.1874 130.69 191.55 172.95 191.77 76.95 173.17 155.63 123.22 181.46 163.99 181.67 73.05 164.20 147.6975 134.91 199.48 180.30 199.71 80.01 180.52 162.40 125.84 187.67 169.85 187.88 75.45 170.06 153.2176 139.12 207.42 187.64 207.65 83.08 187.87 169.17 128.47 193.89 175.72 194.10 77.85 175.93 158.7277 143.34 215.35 194.98 215.59 86.14 195.22 175.94 131.09 200.10 181.58 200.31 80.25 181.80 164.2378 146.20 223.23 202.50 223.47 89.18 202.74 183.08 132.97 207.02 188.31 207.25 82.92 188.53 170.7279 149.05 231.10 210.02 231.35 92.22 210.26 190.22 134.84 213.95 195.03 214.18 85.59 195.25 177.2080 151.91 238.98 217.53 239.23 95.26 217.78 197.36 136.72 220.88 201.76 221.11 88.27 201.98 183.6881 154.77 246.86 225.05 247.11 98.30 225.31 204.50 138.59 227.81 208.48 228.04 90.94 208.71 190.1682 157.63 254.73 232.57 254.99 101.34 232.83 211.63 140.47 234.74 215.21 234.97 93.62 215.43 196.6583 159.70 269.94 247.68 270.20 107.21 247.94 226.51 140.38 248.21 228.92 248.43 98.81 229.15 210.4384 161.77 285.14 262.79 285.40 113.08 263.05 241.38 140.29 261.67 242.64 261.89 104.01 242.86 224.2185+ 163.84 300.35 277.91 300.61 118.95 278.17 256.26 140.21 275.14 256.36 275.36 109.20 256.57 237.99

* Region 11: WV counties: Monongalia

AGE



MALE FEMALE


FHD Plan G Plan N

65 $80.07 $110.77 $99.47 $110.91 $45.40 $99.60 $89.00 $84.87 $114.37 $102.29 $114.51 $46.79 $102.43 $91.1566 84.08 117.14 105.26 117.29 47.87 105.40 94.23 87.65 119.39 106.91 119.53 48.73 107.06 95.3967 88.08 123.51 111.04 123.66 50.33 111.19 99.47 90.43 124.40 111.54 124.56 50.67 111.69 99.6468 92.09 129.89 116.83 130.04 52.79 116.98 104.71 93.21 129.42 116.16 129.58 52.61 116.32 103.8869 96.10 136.26 122.61 136.42 55.25 122.77 109.95 95.99 134.44 120.79 134.60 54.55 120.95 108.1370 100.11 142.63 128.40 142.79 57.71 128.57 115.18 98.77 139.46 125.41 139.60 56.49 125.58 112.3871 104.12 149.00 134.18 149.17 60.17 134.36 120.42 101.55 144.48 130.04 144.65 58.43 130.21 116.6272 108.13 155.37 139.97 155.55 62.63 140.15 125.66 104.33 149.50 134.66 149.67 60.36 134.83 120.8773 111.86 162.38 146.46 162.57 65.34 146.65 131.65 106.65 154.99 139.85 155.17 62.49 140.02 125.7474 115.58 169.40 152.96 169.60 68.05 153.15 137.64 108.98 160.48 145.03 160.67 64.61 145.21 130.6275 119.31 176.42 159.45 176.62 70.76 159.65 143.62 111.30 165.98 150.22 166.16 66.73 150.40 135.4976 123.04 183.44 165.95 183.65 73.47 166.15 149.61 113.62 171.47 155.40 171.66 68.85 155.59 140.3777 126.77 190.46 172.44 190.67 76.18 172.65 155.60 115.94 176.96 160.59 177.16 70.97 160.78 145.2578 129.29 197.42 179.09 197.64 78.87 179.30 161.91 117.60 183.09 166.54 183.29 73.33 166.73 150.9879 131.82 204.39 185.74 204.61 81.56 185.96 168.23 119.25 189.22 172.48 189.42 75.70 172.68 156.7180 134.35 211.35 192.38 211.58 84.25 192.61 174.54 120.91 195.35 178.43 195.55 78.06 178.63 162.4581 136.88 218.32 199.03 218.54 86.94 199.26 180.85 122.57 201.47 184.38 201.67 80.43 184.58 168.1882 139.40 225.28 205.68 225.51 89.63 205.91 187.17 124.23 207.60 190.33 207.80 82.80 190.53 173.9183 141.23 238.73 219.05 238.96 94.82 219.28 200.32 124.15 219.51 202.46 219.71 87.39 202.66 186.1084 143.06 252.18 232.41 252.41 100.01 232.64 213.48 124.07 231.42 214.59 231.62 91.98 214.78 198.2985+ 144.89 265.63 245.78 265.86 105.20 246.01 226.63 124.00 243.33 226.72 243.52 96.58 226.91 210.47

* Region 12: WV counties: Hampshire

AGE

www.healthplan.org

[ This page left blank intentionally. ]

OUTLINE OF MEDICARE SUPPLEMENT PLAN COVERAGETHP Insurance Company (THP)

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

This is only an outline describing your policy’s most important features. The policy is your health insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your health insurance company, THP.

READ YOUR POLICY CAREFULLY

If you find that you are not satisfied with your policy, you may return it to:

THP Insurance Company 52160 National Road East St. Clairsville, OH 43950-9365

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.

RIGHT TO RETURN POLICY

This policy may not fully cover all of your medical costs.Neither THP Insurance Company 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.

NOTICE

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 health coverage and refuse to pay any claims if you leave out or falsify important medical information.Review your application carefully before you sign it. Be certain that all information has been properly recorded.

COMPLETE ANSWERS ARE VERY IMPORTANT

THP Insurance Company 100 Lillian Gish Blvd. P.O. Box 4816 Massillon, OH 44648-4816

or

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.

POLICY REPLACEMENT

www.healthplan.org


III. Benefit Plan Summaries

www.healthplan.org


*A Benefit Period begins on the 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 A Pays You Pay Under Plan A

First 60 days

61 - 90 days

91 days and after:• While using 60 lifetime

reserve days• Once lifetime reserve

days are used: additional 365 days

Beyond the additional 365 days

All but $1,260

All but $315 a day

All but $630 a day

$0

$0

$0

$315 a day

$630 a day

100% of Medicare eligible expenses

$0

$0

$0 ***

All costs

$0

First 20 days21 - 100 days

After 101 days

All approved amountsAll but $157.50 a day

$0

$0$0

$0

$0

Up to $157.50 a dayAll costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN A

***NOTICE: When your Medicare Part A hospital benefits are exhausted, THP Insurance Company 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 “core benefits.” During this time, the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.

First three (3) pints

Additional amounts

$0

100%

3 pints

$0

$0

$0

All but very limited coinsurance for

outpatient drugs and inpatient respite care

Medicare copay/coinsurance

$0

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

Skilled Nursing Facility Care *You must meet Medicare’s requirements, including having been in a hospital for at least three (3) days and entered a Medicare-approved facility within 30 days after leaving the hospital.

Blood

Hospice CareAvailable as long as your doctor certifies you are terminally ill and you elect to receive these services.

$1,260 (Part A Deductible)

*Once you have been billed $147 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.


First $147 of Medicare-approved amounts

Remainder of Medicare-approved amounts

Part B excess charges (above Medicare-approved amounts)

$0

Generally 80%

$0

$0

Generally 20%

$0

$147 (Part B Deductible)

$0

All costs

Medicare (Part B) Medical Services - Per Calendar YearPLAN A


Next $147 of Medicare-approved amounts *

$0

$0

All costs

$0

$0


100% $0 $0

Medical ExpensesIn 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.

Blood

Clinical Laboratory ServicesTests for diagnostic services.


80% 20% $0


Medically necessary skilled care services and medical supplies

100% $0 $0

First $147 of Medicare-approved amounts *

$0 $0 $147 (Part B Deductible)

Parts A & BPLAN A

Home Health Care (Medicare-approved services)

Durable Medical Equipment


80% 20% $0


* A Benefit Period begins on the 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 C Pays You Pay Under Plan C

First 60 days

61 - 90 days





All but $1,260

All but $315 a day

All but $630 a day

$0

$0


$315 a day

$630 a day


$0

$0

$0

$0 ***

All costs

$0


After 101 days


$0

$0Up to $157.50 a day

$0

$0

$0All costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN C



Additional amounts

$0

100%

3 pints

$0

$0

$0




$0



Blood






$0

Generally 80%

$0


Generally 20%

$0

$0

$0

All costs

Medicare (Part B) Medical Services - Per Calendar YearPLAN C



$0

$0

All costs


$0

$0

100% $0 $0


Blood



80% 20% $0



100% $0 $0


$0 $147 (Part B Deductible) $0

Parts A & BPLAN C




80% 20% $0

Other Benefits - Not Covered by Medicare


First $250 each calendar year

$0 $250

Foreign Travel (not covered by Medicare) Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA.

Remainder of charges $0 80% to a lifetime maximum benefit

of $50,000

20% and amounts over the $50,000 lifetime

maximum

$0

* A Benefit Period begins on the 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 D Pays You Pay Under Plan D

First 60 days

61 - 90 days





All but $1,260

All but $315 a day

All but $630 a day

$0

$0


$315 a day

$630 a day


$0

$0

$0

$0 ***

All costs

$0


After 101 days


$0

$0Up to $157.50 a day

$0

$0

$0All costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN D



Additional amounts

$0

100%

3 pints

$0

$0

$0




$0



Blood







$0

Generally 80%

$0

$0

Generally 20%

$0


$0

All costs

Medicare (Part B) Medical Services - Per Calendar YearPLAN D



$0

$0

All costs

$0

$0


100% $0 $0


Blood



80% 20% $0



100% $0 $0



Parts A & BPLAN D




80% 20% $0




$0 $250



of $50,000


maximum


$0


SERVICES Medicare PaysAfter you pay

$2,180 deductible, ** Plan F Pays

In addition to $2,180 deductible,**You Pay

Under Plan F

First 60 days

61 - 90 days





All but $1,260

All but $315 a day

All but $630 a day

$0

$0

$315 a day

$630 a day


$0

$0

$0

$0 ***

All costs

$0


After 101 days


$0

$0Up to $157.50 a day

$0

$0

$0All costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN F or



Additional amounts

$0

100%

3 pints

$0

$0

$0




$0



Blood



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

High-Deductible Plan F

SERVICES Medicare Pays




$0

Generally 80%

$0


Generally 20%

100%

$0

$0

$0

Medicare (Part B) Medical Services - Per Calendar Year



$0

$0

All costs


$0

$0

100% $0 $0


Blood



80% 20% $0

After you pay $2,180 deductible, **

Plan F Pays


Under Plan F

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

PLAN F orHigh-Deductible Plan F



100% $0 $0


$0 $147 (Part B Deductible) $0

Parts A & B




80% 20% $0


SERVICES Medicare Pays Plan F Pays You Pay Under Plan F


$0 $0 $250



of $50,000


maximum

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

After you pay $2,180 deductible, **

Plan F Pays


Under Plan F

PLAN F orHigh-Deductible Plan F


SERVICES Medicare Pays Plan G Pays You Pay Under Plan G

First 60 days

61 - 90 days





All but $1,260

All but $315 a day

All but $630 a day

$0

$0

$315 a day

$630 a day


$0

$0

$0

$0 ***

All costs

$0


After 101 days


$0

$0Up to $157.50 a day

$0

$0

$0All costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN G



Additional amounts

$0

100%

3 pints

$0

$0

$0




$0



Blood








$0

Generally 80%

$0

$0

Generally 20%

100%


$0

$0

Medicare (Part B) Medical Services - Per Calendar Year



$0

$0

All costs

$0

$0


100% $0 $0


Blood



80% 20% $0

PLAN G Plan G Pays You Pay Under Plan G



100% $0 $0



Parts A & B




80% 20% $0


SERVICES Medicare Pays Plan G Pays You Pay Under Plan G


$0 $0 $250



of $50,000


maximum


PLAN G Plan G Pays You Pay Under Plan G


SERVICES Medicare Pays Plan N Pays You Pay Under Plan N

First 60 days

61 - 90 days





All but $1,260

All but $315 a day

All but $630 a day

$0

$0


$315 a day

$630 a day


$0

$0

$0

$0 ***

All costs

$0


After 101 days


$0

$0Up to $157.50 a day

$0

$0

$0All costs

Medicare (Part A) Hospital Services - Per Benefit PeriodPLAN N



Additional amounts

$0

100%

3 pints

$0

$0

$0




$0



Blood






$0

Generally 80%

$0

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.

Medicare (Part B) Medical Services - Per Calendar YearPLAN N



$0 $0 All costs



$0

$0

All costs

$0

$0


100% $0 $0

Blood



80% 20% $0



100% $0 $0



Parts A & BPLAN N




80% 20% $0




$0 $0 $250



of $50,000


maximum


THP Insurance Company, Inc. (THP) Benefits SummaryMedicare Supplement Insurance Policies

Choose the Medicare Supplement insurance policy from THP that best meets your needs and budget.*

Benefit Medicare pays THP Medicare Supplement Insurance Policies PayPlan N

First 60 days

* The purpose of this communication is a solicitation of insurance from THP Insurance Company, Inc. (THP). THP is a private insurance company not endorsed by or connected with the federal Medicare program or the U.S. government. This communication provides a brief summary of coverage, see your agent or contact THP for specific costs and details of the coverage. Benefits vary by policy.

Plan F**Plan CPlan AMedicare Part A hospital care

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

$1,260(Part A deductible)

$1,260(Part A deductible)

$1,260(Part A

deductible)

Days 61 - 90 All but $315 a day $315 a day

Days 91 - 150: while using 60 lifetime reserve days

All but $630 a day $630 a day

Once lifetime reserve days are used: additional 365 days

$0 100% of Medicare eligible expenses

Beyond the additional 365 days $0 $0

Blood - first three pints $0 First three pints

Blood - additional amounts 100% $0

Skilled nursing facility care

First 20 days All approved amounts $0

Days 21 - 100 All but $157.50 a day $0 Up to $157.50 a day

Days 101 and after $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 careMedicare copayment/coinsurance

FORM# OH: OHTHP-85 WV: WVTHP-55

Plan D Plan G

Part B deductible $147

Medicare Part B physician’s services and supplies (per calendar year)

$0 $0$147

(Part B deductible)

$147(Part B

deductible)$0

Coinsurance Generally 80% (after Part B deductible) Generally 20%

Part B - Excess Charges $0

Blood - first three pints $0 First three pints

Blood - next $147 of Medicare approved amounts $0

Blood - remainder of Medicare approved amounts 80%

Preventive benefits for Medicare covered services

Generally 75% or more of Medicare approved

amountsRemainder of Medicare approved amounts

Additional benefitsForeign Travel - Emergency care outside U.S.

$0 80% to a lifetime maximum benefit of $50,000 (after $250 annual deductible)

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.

$0 $0 100% $0

$0$147

(Part B deductible)

$0

20%

$0

** Plan F also has an option called High Deductible Plan F. This high deductible plan pays the same or offers 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 are $2,180. Out-of-pockets expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Parts A and B, but do not include the plan’s separate foreign travel emergency deductible.

Benefit Medicare pays THP Medicare Supplement Insurance Policies PayPlan NPlan F**Plan CPlan A Plan D Plan G

$0 $0

$147 (Part B

deductible)$0 $0

THP Medicare Supplement Insurance Guaranteed Issue Guide Guaranteed issue means your automatic acceptance into specific Medicare Supplement insurance policies without having to complete the “Statement of Health” section of the application. How to use this Guide 1. Review the “Situations” and “Plan If this Medicare Supplement insurance policy is Options” in this guide. Pay special replacing Medicare Advantage plan coverage, you Attention to the “Time Frame” must request, in writing, to be disenrolled from

requirements. your Medicare Advantage plan. Your written request will formally confirm that you are dis-

enrolling from your Medicare Advantage plan and replacing it with a Medicare Supplement

2. Turn to the “Guaranteed Issue” policy. section of the application. Circle your applicable “Situation” number. If you have any questions about this process, You may skip the “Statement of please contact your Medicare Advantage plan. Health” section of the application.

3. Submit required documentation. You must attach proof of the date your previous coverage ended. (Example: A letter from your insurance company giving the dates your coverage began and ended.)

FORM# OH: OHTHP-84 WV: WVTHP-54 1

Medicare Supplement Guaranteed Issue Guide

2

1. Situation You are 65 years of age or older and are newly enrolled in Medicare Part B. description

Options If age 65 or older: All plans available from us Time frame- You must submit your application no later than six (6) months after the date your open enrollment Medicare Part B coverage took effect. period 2. Situation Upon first becoming eligible for Medicare Part A for benefits at age 65 or older, description you enroll in a Medicare Advantage Plan under Medicare Part C, or with a PACE provider under Section 1894 of the Social Security Act, and disenroll from the plan or program by no later than 12 months after the effective date of enrollment. Options If age 65 or older: All plans available from us Time Frame If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 3. Situation You enrolled with an employee welfare benefit plan that provides benefits that description supplement Medicare, but the plan terminated or stopped providing all such supplemental benefits; or you enrolled with an employee welfare benefit plan that is primary to Medicare and the plan terminates, or the plan ceases to provide all health benefits to you because you disenrolled from the plan.

Options If age 65 or older: All plans available from us Time frame Your guaranteed issue period begins on the later of the date you receive a notice of termination or cessation of all supplemental health benefits (or, if a notice is not received, notice that a claim has been denied because of such a termination or cessation), or the date that the applicable coverage terminates or ceases, and ends 63 days thereafter.


3

4. Situation A. You enrolled in one of the following:

description ● A Medicare Advantage plan; or ● A PACE provider, if you are 65 years of age or older And

B. One of the following occurs: ● You involuntarily lost coverage because: -Your organization lost its certification; -Your organization stopped providing the plan in your area; -You moved, or a specified change in your circumstance caused you to no longer be eligible for your plan, or the plan terminated for everyone in your residential area. This section does not apply if you lost eligibility because you failed to pay premium or engaged in disruptive behavior.

Or ● You voluntarily terminated coverage but can demonstrate that: - The organization substantially violated a material provision of its contract with you; or

-The organization or its representative materially misrepresented plan provisions in marketing to you; or -You meet such other exceptional conditions as the Secretary may provide.

Options If age 65 or older: All plans available from us. Time Frame If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date.

5. Situation A. You enrolled in one of the following: description ● An eligible Medicare cost organization;

● A health care prepayment plan; or ● A Medicare SELECT policy And B. One of the following occurs:

● You involuntarily lost coverage because - Your organization lost its certification; - Your organization stopped providing the plan in your area; - You moved, or a specified change in your circumstance caused you to


4

no longer be eligible for your plan, or the plan terminated for everyone in your residential area. This section does not apply if you lost eligibility because you failed to pay premium or engaged in disruptive behavior. Or ● You voluntarily terminated coverage but can demonstrate that: - The organization substantially violated a material provision of its

contract with you; or - The organization or its representative materially misrepresented plan provisions in marketing the plan to you; or - You meet such other exceptional conditions as the Secretary may provide. Options If age 65 or older: All plans available from us.

Time Frame If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date.

6. Situation You enrolled in a Medicare Supplement policy, but your coverage ended description involuntarily because of: ● The issuer’s insolvency or the non-issuer organization’s bankruptcy; Or ● Another involuntary coverage or enrollment termination. Options If age 65 or older: All plans available from us. Time Frame Your guaranteed issue period begins on the earlier of the date on which you receive notice of termination, notice of bankruptcy, or a similar notice, or the date on which your coverage was terminated and ends 63 days after coverage terminates. 7. Situation You enrolled in a Medicare Supplement policy, and you voluntarily terminated your description coverage because: ● The insurer substantially violated a material provision of the policy; Or ● The insurer or its representative materially misrepresented a policy provision to you.


5

Options If age 65 or older: All plans available from us. Time Frame If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date. 8. Situation You enrolled in a Medicare Supplement policy. You terminated that Medicare description Supplement policy and enrolled, for the first time, in a Medicare Advantage plan, an eligible Medicare risk or cost program, a similar organization under a demonstration project, a Medicare SELECT policy, or a PACE provider, and terminated that enrollment within the first 12 months. Options If age 65 or older: The same Medicare Supplement policy in which you were most recently enrolled, if available from the same insurer, or, if not available, all plans available from us. Time Frame If your enrollment is involuntarily terminated, your guaranteed issue period begins on the date you receive termination notice and ends 63 days after your coverage is terminated. If your enrollment is voluntarily terminated, your guaranteed issue period begins 60 days before your disenrollment date and ends 63 days after your disenrollment date.

www.healthplan.org


100 Lillian Gish Blvd. P.O. Box 4816Massillon, OH 44648Toll-free: 1.877.236.2290TTY/TDD: 1.877.236.2291

52160 National Road EastSt. Clairsville, OH 43950Toll-free: 1.877.847.7915TTY/TDD: 1.800.622.3925

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