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Comprehensive Long-Term Care Insurance
Outline of Coverage
Form H-HX-LTC (13)
The contract is an approved long-term care insurance contract under California law and regulations.
However, the benefits payable by the contract will not qualify for Medi-Cal asset protection under the
California Partnership for Long-Term Care. For information about policies and certificates qualifying
under the California Partnership for Long-Term Care, call the Health Insurance Counseling and
Advocacy Program at the toll-free number, 1-800-434-0222.
This contract for long-term care insurance is intended to be a federally qualified long-term care
insurance contract and may qualify you for federal and state tax benefits.
CAUTION:
If your answers on the application are misstated or untrue, Thrivent Financial for Lutherans (called we,
us and our in this outline) may have the right to deny benefits or rescind your contract. The issuance of
this long-term care insurance contract is based on, in part, your responses to the questions on your application.
A copy of your application will be attached to any issued contract. The best time to clear up any questions is now,
before a claim arises! If, for any reason, any of your answers are incorrect, contact us at 4321 N. Ballard Road,
Appleton, Wisconsin 54919-0001.
NOTICE TO BUYER
This contract may not cover all of the costs associated with long-term care incurred by the buyer during
the period of coverage. The buyer is advised to review carefully all contract limitations.
1. This contract is an individual contract of insurance.
2. PURPOSE OF THE OUTLINE OF COVERAGE.
This outline of coverage provides a very brief description of the important features of the contract. You should
compare this outline of coverage to outlines of coverage for other contracts available to you. This is not an
insurance contract but only a summary of coverage. Only the individual contract contains governing
contractual provisions. This means that the contract sets forth in detail the rights and obligations of both you
and the insurance company. Therefore, if you purchase this coverage, or any other coverage, it is important
that you READ YOUR CONTRACT CAREFULLY!
3. TERMS UNDER WHICH THE CONTRACT MAY BE RETURNED AND PREMIUM REFUNDED.
30-Day Right to Cancel: Within the first 30 days of receiving your contract, you may cancel it for any reason.
The contract will be deemed void from the beginning and we will refund any premium paid within 30 days after
we receive notice of cancellation and the returned contract.
Unearned Premium Refunds:
If you cancel your contract after 30 days of first receiving it, the portion of any premium paid beyond the date
of cancellation will be refunded. If your contract terminates due to your death or because your Available
Benefit has been reduced to zero, the portion of any premium paid beyond the date of termination will be
refunded.
4. THIS CONTRACT IS NOT A MEDICARE SUPPLEMENT CONTRACT.
If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from
us. Neither Thrivent Financial for Lutherans, nor its agents represent Medicare, the federal government, or any
state government.
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5. LONG-TERM CARE COVERAGE.
Contracts of this category are designed to provide coverage for one or more necessary diagnostic, preventive,
therapeutic, rehabilitative, maintenance or personal care services provided in a setting other than an acute
care unit of a hospital, such as in a nursing home, in the community or in the home.
This contract provides coverage in the form of reimbursement for expenses that you incur for Qualified Long-
Term Care Services when Eligibility for Benefits is met. Payment is subject to the Elimination Period,
Maximum Monthly Benefit, Available Benefit, Exceptions and Limitations and all other terms and conditions of
the contract.
6. BENEFITS PROVIDED BY THIS CONTRACT.
a) Contract Benefit Limits:
A. Maximum Monthly Benefit: $
(enter amount)
B. Benefit Multiplier:
24 months 36 months 48 months 60 months 96 months
C. Available Benefit (A. x B. = C.): $ (enter amount)
Elimination Period:
30 days 90 days 180 days
Increase Benefit Riders:
Compound 1% Compound 2% Compound 3% Compound 5% Flexible 5%
Cash Benefit Rider
Nonforfeiture Benefit Rider
Return of Premium upon Death Rider
Shared Care Rider
Survivorship Rider
Waiver of Elimination Period for Home and Community-Based Care Rider
b) Institutional Benefits:
Care Facility Benefit.
Care Facility Benefit pays for services while you are confined in a nursing home, residential care facility, or
hospice. In California, a residential care facility means a facility licensed as a residential care facility for the
elderly or a residential care facility as defined in the California Health and Safety Code and operated
pursuant to state and federal law.
Bed Reservation Feature.
Bed Reservation Feature provides that the Care Facility Benefit will not be interrupted by a temporary
absence from the facility where you are a resident.
c) Non-Institutional Benefits:
Your contract includes benefits for Qualified Long-Term Care Services that are provided in an Adult Day
Care Facility or in your home as Home Care Services.
Home Care Services.
Home Care Services are Qualified Long-Term Care Services that are provided in your place of residence
or in an Adult Day Care Facility. Home Care Services include home health care, adult day care, personal
care, homemaker services, hospice services and respite care.
The contract also includes the following benefits:
Alternate Care Benefit.
If your Plan of Care prescribes Qualified Long-Term Care Services that are not covered by the contract, we
may pay benefits for such additional services if you, us, and your Licensed Health Care Practitioner agree
to a written alternate care benefit agreement.
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Supplemental Benefits.
Supplemental Benefits are provided for Qualified Long-Term Care Services under Supplemental Respite
Care, Equipment/Home Modification, Caregiver Training and International Care. These benefits are not
subject to the Elimination Period or the Maximum Monthly Benefit. Each benefit is subject to its own
separate benefit limit and the Available Benefit.
• Supplemental Respite Care.
Supplemental Respite Care is designed to relieve an informal caregiver on a short-term basis and is
provided in a care facility, adult day care facility, or a person's home as Home Care Services.
• Equipment/Home Modification.
Equipment/Home Modification provides coverage for special equipment and home modifications as
specified in your Plan of Care.
Special equipment includes, but is not limited to, a hospital bed, wheelchair, crutches or walker or
safety-related equipment such as a medical alert system.
Home modifications include, but are not limited to, home safety checks to evaluate your home,
accessibility changes such as a ramp, chair-lift or alterations to accommodate a wheelchair or
safety-related changes such as installation of grab bars or railings.
• Caregiver Training.
Caregiver Training means training that is (1) specified in your Plan of Care and (2) provided to your
informal caregiver by a person who is licensed, certified or otherwise qualified to provide the training.
• International Care.
International Care provides limited coverage for Qualified Long-Term Care Services received
outside of the United States.
d) Eligibility for the Payment of Benefits:
Your contract covers only Qualified Long-Term Care Services.
Qualified Long-Term Care Services are necessary diagnostic, preventive, therapeutic, curative,
treatment, mitigation and rehabilitative services and maintenance or personal care services that are:
• Required by a Chronically Ill individual; and
• Provided pursuant to a Plan of Care.
To be eligible for benefits under this contract, all of the following Conditions on Eligibility for Benefits
must be met:
• You are Chronically Ill and receive Qualified Long-Term Care Services specified in a Plan of Care;
• The Elimination Period has been met, when applicable; and
• Coverage is not excluded.
Chronically Ill means that a licensed health care practitioner has within the preceding 12-month period
certified in writing that you:
• Have a Physical Impairment that is expected to last at least 90 days. A Physical Impairment
prevents you from performing two or more of the following Activities of Daily Living without
substantial assistance from another person: bathing, continence, dressing, eating, transferring or
toileting; or
• Require Substantial Supervision to protect yourself from threats to health and safety due to Severe
Cognitive Impairment.
Substantial Supervision means continual supervision (which may include cuing by verbal prompting,
gestures or other demonstrations) by another person that is necessary to protect the severely
cognitively impaired individual from threats to his or her health or safety (such as may result from
wandering).
Severe Cognitive Impairment means a loss or deterioration in intellectual capacity that is:
a) Comparable to (and includes) Alzheimer's disease and similar forms of irreversible dementia; and
b) Measured by clinical evidence and standardized tests that reliably measure impairment in the
individual's short-term or long-term memory, orientation as to people, places or time, and
deductive or abstract reasoning.
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A Plan of Care is a written description of your needs and a specification of the type, frequency and
providers of all formal and informal long term care services required by you, and the cost, if any. The Plan
of Care must be developed by a licensed health care practitioner.
Care Coordinator Services.
A care coordinator can help develop your Plan of Care. Care Coordinator Services are offered to assist in
identifying care needs and community resources available to deliver care while you are Chronically Ill. If
you contact us and use a care coordinator referred to you by us, these services are provided at no cost to
you and are not subject to the Elimination Period.
Contingent Nonforfeiture Benefit.
Your contract includes a Contingent Nonforfeiture Benefit provision. This benefit provides you the option to
reduce your coverage or convert to a reduced paid-up contract in the event of a substantial premium
increase.
The paid-up coverage will have an Available Benefit equal to the lesser of the Nonforfeiture Credit and the
Available Benefit in effect immediately before the date paid-up coverage becomes effective. The
Nonforfeiture Credit is equal to the greater of the total of all premiums paid by you and applied to your
contract and the Maximum Monthly Benefit in effect on the date paid-up coverage becomes effective.
Benefits will be paid subject to all of the conditions and limitations of your contract. All optional benefit
riders on your contract will terminate on the date paid-up coverage becomes effective. Paid-up coverage
will terminate on the date the Available Benefit reaches zero.
e) Optional Benefits.
For an additional cost, you may elect any of the optional benefit riders listed below.
Nonforfeiture Benefit.
After your contract has been in force for three years, the Nonforfeiture Benefit rider provides paid-up
coverage if you give us notice to cancel your contract or your contract terminates for nonpayment of
premium.
The paid-up coverage will have an Available Benefit equal to the lesser of the Nonforfeiture Credit and the
Available Benefit in effect immediately before the date paid-up coverage becomes effective. The
Nonforfeiture Credit is equal to the greater of the total of all premiums paid by you and applied to your
contract and three times the Maximum Monthly Benefit in effect on the date paid-up coverage becomes
effective.
Benefits will be paid subject to all of the conditions and limitations of your contract. All optional benefit
riders on your contract will terminate on the date paid-up coverage becomes effective. Paid-up coverage
will terminate on the date the Available Benefit reaches zero.
Shared Care Benefit.
The Shared Care Benefit rider allows you and your benefit partner to share each other's Available Benefit if
one of you exhausts his or her own Available Benefit. You and your benefit partner must each own a
Thrivent Financial for Lutherans long-term care insurance contract with identical coverage issued on the
same date that includes this rider and names each other as a benefit partner.
Survivorship Benefit.
The Survivorship Benefit rider will waive your premiums for life if after ten years from the date of issue of
the rider your benefit partner dies. The premiums waived will be those for your contract's current coverage
in effect at the time of your benefit partner's death. This benefit will not be paid if either you or your benefit
partner was Chronically Ill within the first ten years from the date of issue of the contract. You and your
benefit partner must each own a Thrivent Financial for Lutherans long-term care insurance contract with
the same date of issue that includes this rider and names each other as a benefit partner.
Waiver of Elimination Period for Home and Community-Based Care.
The Waiver of Elimination Period for Home and Community-Based Care rider will waive the Elimination
Period requirement when receiving benefits for Home Care Services. The days of care you receive will still
help you satisfy the Elimination Period for other types of care that may be needed in the future.
Return of Premium upon Death.
The Return of Premium upon Death rider will return premiums paid (less any benefits paid and
accumulated dividends paid upon death) to your estate if you die and your rider has been in force for at
least ten years. Benefits paid under this rider will reduce your Available Benefit. This benefit may have tax
implications for your estate. You are advised to consult a tax advisor.
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Cash Benefit.
In any calendar month in which you receive Long-Term Care Benefits for expenses incurred on at least five
separate days and your Elimination Period has ended, the Cash Benefit rider pays you a benefit equal to:
• 15% of your Maximum Monthly Benefit in effect on the last day of the calendar month if on any of
those days you receive Home Care Services, other than respite care provided in a Care Facility;
otherwise
• 10% of your Maximum Monthly Benefit in effect on the last day of the calendar month.
Benefits paid under this rider will not reduce your Available Benefit. This rider may have tax implications.
You are advised to consult a tax advisor.
7. LIMITATIONS AND EXCLUSIONS.
a) Pre-existing Conditions Coverage: Your contract does not exclude pre-existing conditions.
b) Non-eligible Facilities/Providers: Your contract does not cover services provided by a facility or agency
that does not meet the contract definition for such facility or agency, except as provided under the Alternate
Care Benefit. This contract does not cover services provided in a clinic, hospital, sanatorium, or a home or
facility for the treatment of alcoholism or drug addiction.
c) Non-eligible Levels of Care: Your contract does not cover services that are not Qualified Long-Term Care
Services as defined in the contract.
d) Exclusions/Exceptions and Limitations: Your contract does not pay benefits for:
• Charges billed by a doctor;
• Charges for prescription drugs;
• Services outside the United States, its territories and possessions except under the International Care
Benefit;
• Services provided due to an attempt at suicide, whether or not you have the mental capacity to control
what you are doing, or an intentionally self-inflicted injury;
• Services provided for the treatment of alcoholism or drug addiction.
• Care or services provided by an immediate family member.
• Which benefits are payable under any state or federal workers' compensation, employer's liability or
occupational disease law;
• Expenses which are reimbursable under Medicare or would be reimbursable under Medicare but for the
application of a deductible or coinsurance amount;
• Expenses that are paid under any other contracts or riders issued by us.
THIS CONTRACT MAY NOT COVER ALL THE EXPENSES ASSOCIATED WITH YOUR LONG-TERM CARE
NEEDS.
8. RELATIONSHIP OF COST OF CARE AND BENEFITS.
Because the cost of long-term care services will likely increase over time, you should consider whether and
how the benefits under this contract may be adjusted. For this purpose, you may add an Annual Increase
Benefit rider or a Flexible Increase Benefit rider for an additional cost.
An optional Compound Annual Increase Benefit rider increases your Maximum Monthly Benefit, Available
Benefit and Supplemental Benefit Limits on each rider anniversary by either 5%, 3%, 2% or 1% (depending on
which rider your select) of the corresponding amounts in effect immediately before the increase. Premiums for
this rider are set at the time of issue. Increases in coverage under this rider will not cause an increase in your
contract's premium.
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An optional Flexible Increase Benefit rider increases your Maximum Monthly Benefit, Available Benefit and
Supplemental Benefit Limits on each rider anniversary by 5% of the corresponding amounts in effect
immediately before the increase. You may decline the increase. If you decline three consecutive increases,
automatic annual increases will cease and future increases will be provided only on rider anniversaries
occurring while premiums are being waived under the Waiver of Premium provision of the contract. Premiums
for this rider are set at the time of issue. Your contract's premium will increase with each option elected and
will be based on your age at the time of the increase.
The contract does not include a guaranteed option to purchase additional benefits in the future.
At the end of this outline is a graphic comparison of the benefit levels of a contract that includes the increase
benefit over the coverage period with a contract that does not include the increase benefit. A relative cost
comparison chart illustrates long-term care contract premiums with and without the increase benefit.
9. TERMS UNDER WHICH THE CONTRACT MAY BE CONTINUED IN FORCE OR DISCONTINUED.
RENEWABILITY: THIS CONTRACT IS GUARANTEED RENEWABLE. This means you have the right,
subject to the terms of your contract, to continue this contract as long as you pay your premiums on time.
Thrivent Financial for Lutherans cannot change any of the terms of your contract on its own, except that, in the
future, IT MAY INCREASE THE PREMIUM YOU PAY.
WAIVER OF PREMIUM BENEFIT.
We will waive any premiums that come due while you incur expenses for Qualified Long-Term Care Services
for which long-term care benefits are payable. When such expenses are no longer incurred, premiums will
cease to be waived and you must resume paying premiums in order to keep your contract in force. Expenses
eligible for Supplemental Benefits will not trigger Waiver of Premiums.
TERMS UNDER WHICH THE COMPANY MAY CHANGE PREMIUMS.
After your contract has been in force for five years, we may change the premium for the contract but
not more frequently than once a year. Any change will apply to all contracts issued in your state on
this contract form. We will not change the premium due to changes in your health or due to any claims
on your contract.
10. ALZHEIMER'S DISEASE, ORGANIC DISORDERS, AND RELATED MENTAL DISEASES.
This contract includes benefits for persons who are clinically diagnosed as having Alzheimer's disease,
organic disorders, or related degenerative and dementing illnesses and meet the qualifying for benefits
requirements described in the contract.
11. PREMIUM.
The total annual premium for your contract including the optional benefits is listed below.
Base Contract $
Cash Benefit Rider $
Compound Annual Increase Benefit Rider (5%, 3%, 2% or 1%) $
Flexible Increase Benefit Rider $
Nonforfeiture Benefit Rider $
Return of Premium upon Death Rider $
Shared Care Rider $
Survivorship Rider $
Waiver of Elimination Period for Home and Community-Based Care Rider $
Total Annual Premium $
Your premium will be on a basis.
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12. ADDITIONAL FEATURES.
The issuance of the contract is subject to medical underwriting.
Unintentional Lapse. You may designate at least one person other than yourself to receive notice of
termination for nonpayment of premium. After a premium remains in default for 30 days, we will give this
notice to you and any persons whom you have designated to receive such notice.
13. INFORMATION AND COUNSELING. The California Department of Insurance has prepared a Consumer
Guide to Long-Term Care Insurance. This guide can be obtained by calling the Department of Insurance toll-
free telephone number. This number is 1-800-927-HELP. Additionally, the Health Insurance Counseling and
Advocacy Program (HICAP) administered by the California Department of Aging, provides long-term care
insurance counseling to California senior citizens. Call the HICAP toll-free telephone number 1-800-434-0222
for a referral to your local HICAP office.
The address and phone number of your local HICAP office is:
Name of HICAP office Phone
Address
City
State
ZIP code
Comparisons of Maximum Monthly Benefits with and without the Annual Increases (Graph 1) and
Comparison of Annual Premiums for Different Annual Increase Options (Graph 2)
This data is shown for a 55 year old female with a $5,000 Maximum Monthly Benefit and Benefit Multiplier of
4 years. There is a 90 day Elimination Period and premiums are made annually for the life of the insured.
There are no marital or underwriting discounts applied and no additional riders selected. For the Flexible
Increase Benefit this assumes no increases are declined by the insured.
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