Your Medical Benefits

Staying healthy is everyone's priority! You do your part by taking care of yourself, and The Texas Annual Conference of the United Methodist Church (TAC) provides two valuable medical coverage options to help you protect your health and that of your family. You get to choose which plan best fits your needs and your budget.

Who is eligible?

About your medical options for active employees

Compare your medical options and coverage

Which plan is right for you?

2016 Rate schedule

Finding in-network (PPO) providers

Out-of-network participant liability

Who is eligible?

As an active clergy, you and your eligible dependents are eligible for the TAC Group Health Plan if you meet the following criteria:

  • You are appointed by the Bishop of the Texas Annual Conference (TAC) to a TAC local church or eligible Extension Ministry as designated in Group Health Benefits Policy 102 (please refer to GHB Policies under Useful Information on this website);
  • You work 30 or more hours a week (as indicated by a 75% or 100% appointment on your salary sheet).  For student pastors, scheduled hours of academic classes plus time worked at the local church count toward the 30 hours requirement.
  • You provide the required clergy contribution for Group Health.

Clergy appointed to Medical Leave by the TAC can continue on the Group Health Plan as long as they are eligible for Medical Leave based on the eligibility rules of the Comprehensive Protection Plan.

Part-time clergy working on average less than 30 hours per week (appointed 50% or less) are not eligible for participation in the TAC Group Health Plan.

If you are a retired clergy, please see Your Retiree Benefits.

As an active lay employee, you and your eligible dependents are eligible for the TAC Group Health Plan if you meet the following criteria:

  • You are an employee of the TAC Fiscal Office and
  • You work an average of at least thirty (30) hours per week.

If you are a retired lay employee, please see Your Retiree Benefits.

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About your medical options for active employees

Eligible employees can enroll in either the Standard PPO Plan or the High-deductible PPO Plan. Both plans:

  • Provide comprehensive, high-quality care at a reasonable cost for both you and TAC.
  • Are PPO (preferred provider organization) plans. That means TAC has contracted with a network of doctors, hospitals and other providers for care at reduced rates. You don't have to go to a network provider for care, but you'll pay less out of your own pocket if you do.
  • Pay 100% of the cost of preventive and wellness care. Preventive care includes annual physical checkups, recommended screenings for your age and immunizations.
  • Require pre-certification of non-emergency inpatient hospital services and certain outpatient services through Prime Dx, our utilization review manager.
  • Are self-insured, which means the covenant community pays your claims—not an insurance company. That's one of the reasons we emphasize our Wellness Program—it's better for everyone when we're all as healthy as we can be!
  • Include automatic enrollment in the Aetna Resources for Living Employee Assistance Program (EAP) to help you and your family members cope with life issues relating to work, home and personal relationships. You'll also have access to counseling services under an Exclusive Provider Organization (EPO) arrangement, as well as mental health benefits under your PPO plan.

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Standard PPO plan

This is the more "traditional" of the two medical plans, and it costs you more each month for coverage than the high-deductible PPO plan. Here's an overview of how it works:

  • You pay a fixed co-pay for in-network doctor visits.
  • For most other services, you must first pay a $700 annual deductible ($2,100 maximum for family coverage) before the plan begins to pay benefits.
  • Employee Participants who have attended the Day of Wellness by 12/31/15 will receive a $200 credit towards the $700 annual deductible for the employee and each enrolled child. Enrolled spouses who have attended the Day of Wellness by 12/31/15 will also receive the $200 deductible credit. Subsequent to the credit, deductible levels for 2016 are as follows: 
    • PPO Plan - $500 (single) / $1,500 (family maximum)
  • The plan generally pays 80% of the cost of covered services when you see a network provider, and you pay 20%. If you go outside the network for treatment,the plan pays 60% of the maximum eligible charge, and you pay 40% plus any balance billing (see Out-of-network participant liability).
  • Except for emergencies, you, your doctor, or a family member need to pre-certify any inpatient hospital admissions and certain outpatient services through Prime Dx; otherwise, the medical services may not be covered and/or medically necessary in which case the participant would be responsible for all charges. Prime Dx should be notified on the first business day following an emergency hospitalization and within 30 days of a participant learning she is pregnant. Learn more about utilization review with Prime Dx.
  • Once you reach your annual "out-of-pocket" maximum, the plan pays 100% of the cost of eligible expenses for the remainder of the calendar year. Keep in mind, the out-of-pocket maximum for non-network services is much higher—you really save by going to network providers! The out-of-pocket maximum now includes deductibles, co-pays and co-insurance.
  • When you enroll in this medical plan, you're automatically enrolled in the prescription drug plan. There is a separate $50 individual or $100 family prescription drug deductible each year in addition to the medical deductible.

Read more details about the Standard PPO plan.

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High-deductible PPO plan

This plan costs you less each month for coverage than the Standard PPO plan, but you must meet a higher deductible before the plan begins to pay benefits. If you enroll in this plan, you can also participate in a health savings account, a tax-free way to pay your deductible expenses and build savings for future medical expenses.

  • You pay for all medical services and prescription drug expenses out of your own pocket until you reach the combined medical and prescription drug $1,500 annual deductible amount ($3,000 maximum for family coverage).
  • Employee participants who have attended the Day of Wellness by 12/31/15 will receive a $200 credit towards the $1,500 annual deductible for the employee and each enrolled child. Enrolled spouses who have attended the Day of Wellness by 12/31/15 will also receive the $200 deductible credit. Subsequent to the credit, deductible levels for 2016 are as follows: 
    • High-deductible Plan - $1,300 (single) / $2,600 (family maximum)
  • Once you reach your annual deductible:
    • The plan generally pays 80% of the cost of covered services when you see a network provider, and you pay 20%. If you go outside the network for treatment, the plan pays 60% of the maximum eligible charge, and you pay 40% plus any balance billing (see Out-of-network participant liability).
    • The plan pays 80% of your prescription drug costs, and you pay 20%.
  • Except for emergencies, you, your doctor, or a family member need to pre-certify any inpatient hospital admissions and certain outpatient services through Prime Dx; otherwise, the medical services may not be covered and/or medically necessary in which case the participant would be responsible for all charges. Prime Dx should be notified on the first business day following an emergency hospitalization and within 30 days of a participant learning she is pregnant. Learn more about utilization review with Prime Dx.
  • Once you reach your annual "out-of-pocket" maximum, the plan pays 100% of the cost for the remainder of the calendar year. Keep in mind, the out-of-pocket maximum for non-network services is much higher—you really save by going to network providers! The out-of-pocket maximum now includes deductibles, co-pays and co-insurance.

Read more details about the high-deductible PPO plan.

Learn about opening a health savings account.

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Compare your medical options and coverage

Covered services are mostly the same under both plans. Note your savings by using network providers. Be sure to check your monthly cost of coverage as you're deciding which plan to choose.

  Standard PPO plan High-deductible PPO plan
Annual medical deductible Individual $700
Family $2,100
$200 credit if you attend Day of Wellness
Individual $1,500
Family $3,000 
Combined medical and 
prescription drug deductible 
$200 credit if you attend Day of Wellness
Annual prescription drug deductible Individual $50
Family $100 
(in addition to medical deductible above)
Included in annual combined medical and prescription drug deductible (above)

Annual out-of-pocket maximum - medical
includes deductibles, co-pays and co-insurance

In-network Individual $4,200
                  Family $8,700 
Out-of-network Individual $52,000
No family maximum: $52,000 applies to each family member 
Applies to medical expenses only
In-network Individual $4,650
                  Family $12,700 
Out-of-network Individual $52,000
No family maximum: $52,000 applies to each family member 
Applies to medical and prescription drug expenses

Annual out-of-pocket maximum – prescription drugs

Individual $2,000
Family $4,000
Prescription drug expenses only
(in addition to medical out-of-pocket maximum above)
Included in annual combined medical and prescription drug out-of-pocket maximum (above)
Annual maximum benefit None
Houston Methodist Hospital/ETMC benefits Yes No
Eligible to open health savings account? No Yes
Physician office visits

In-network $20 copay primary care doctor; $30 specialist

Out-of-network Plan pays 60% of maximum eligible charge after deductible

In-network Plan pays 80% after deductible

Out-of-network Plan pays 60% of maximum eligible charge after deductible

Preventive care Plan pays 100%, no deductible, in or out of network. Includes lab and X-rays performed outside doctor's office.
Prescription drug benefits Script Care prescription drug plan Discount card only until you meet annual medical deductible, then plan pays 80%
Maternity (initial prenatal visit to determine pregnancy)

In-network $20 copay

Out-of-network Plan pays 60% of maximum eligible charge after deductible

In-network Plan pays 80% after deductible

Out-of-network Plan pays 60% of maximum eligible charge after deductible

Maternity (all other services) In-network Plan pays 80% after deductible
Out-of-network Plan pays 60% of maximum eligible charge after deductible
Hospital services
Before you decide NOT to use a Methodist Hospital or ETMC facility, see Special Hospital Benefits

In-network Plan pays 80% after deductible

Out-of-network Plan pays 60% of maximum eligible charge after deductible

Emergency room (true medical emergency) Plan pays 80% after deductible (in or out of network)
Emergency room (nonemergency)

In-network Plan pays 80% after deductible

Out-of-network Plan pays 60% of maximum eligible charge after deductible

Mental health (inpatient care)
(All inpatient care must be pre-certified through Prime Dx. Inpatient care includes both acute care and residential treatment, if medically necessary.)

In-network Plan pays 80% after deductible
Out-of-network Plan pays 60% of maximum eligible charge after deductible

Alcohol/substance abuse treatment limited to three (3) separate series of treatments.

Mental health (outpatient care)

In-network Plan pays 80% after deductible
Out-of-network Plan pays 60% of maximum eligible charge after deductible

Mental health (office visit)
(no limit on the number of visits)

In-network $20 co-pay Primary Care or $30 co-pay Specialist; then plan pays 100%

Out-of-network Plan pays 60% of maximum eligible charge after deductible

In-network Plan pays 80% after deductible

Out-of-network Plan pays 60% of maximum eligible charge after deductible

All other covered expenses In-network Plan pays 80% after deductible
Out-of-network Plan pays 60% of maximum eligible charge after deductible

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Which plan is right for you?

Only you can decide which medical plan best fits your situation. But here are some things to consider:

  • The standard PPO is often chosen by people who have an existing medical condition, who take a number of prescription drugs regularly, and/or who anticipate a surgery, hospitalization or childbirth.
  • The high-deductible PPO is often chosen by people who are younger, who have healthy (or no) children, who take fewer prescription drugs, and who don't anticipate major medical costs or hospitalizations.

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2016 Rate Schedule

The 2016 clergy rate schedule lists the monthly contributions paid by active clergy for the standard plan or high-deductible plan.

The 2016 lay employee rate schedule lists the monthly contributions paid by active lay employees of the TAC Fiscal Office for the standard plan or high-deductible plan.

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Finding in-network (PPO) providers

Aetna Signature Administrators is the PPO network. Provider information can be found at www.aetna.com/asa or contact Boon Chapman’s customer service number at 1-800-252-9653for help in locating a provider or questions regarding the PPO network.

Aetna Signature Administrators is your Preferred Provider Organization (PPO) network for your medical plans.  You need to select providers from the PPO network in order to get the highest (in-network) benefits under the plan (see Compare your medical options and coverage).  Go to www.aetna.com/asa to look for medical providers in your area.  You can search by location or by the provider name if you have one.  Under the “Advanced Search” tab, you can select a particular hospital affiliation and find providers who have privileges at the various Houston Methodist and ETMC Hospital locations. 

You can also contact Boon Chapman’s customer service number at 1-800-252-9653 for help in locating a provider.  You should always confirm a provider’s participation in the PPO network by contacting the provider directly prior to utilizing their services.

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Out-of-network participant liability

Utilizing an out-of-network provider is an option for plan participants.  However, there are certain factors to be aware of if going out-of-network:  a higher co-insurance will be paid by the participant (40% vs. 20% after any deductible owed) and a much larger out-of-pocket maximum will apply.  You could also be subject to “balance billing.”

Out-of-network providers have not agreed to the contractual rate limitations agreed to by in-network providers.  Out-of-network providers can charge whatever fees they choose, which are significantly higher than in-network provider rates.  With an out-of-network provider claim, the plan administrator (Boon-Chapman) will determine a "Maximum Eligible Charge" for the procedures being billed and pay 60% of the Maximum Eligible Charge amount (after any deductible owed); the participant will pay 40% of the Maximum Eligible Charge. In addition, the participant is responsible for 100% of the difference between the "Maximum Eligible Charge" and the amount the provider charges.  This is referred to as “balance billing.” 

Example: An out-of-network provider charges $50,000 for a surgical procedure. Boon-Chapman determines that the "Maximum Eligible Charge" for the surgery is $30,000. The plan pays 60% of the "Maximum Eligible Charge" $30,000 amount or $18,000. The participant owes 40% of "Maximum Eligible Charge" or $12,000 plus the $20,000 difference between the "Maximum Eligible Charge" amount and the $50,000 fee the out-of-network provider is charging. In this example, the plan would pay $18,000 and the participant would owe a total of $32,000.

Note:  Expenses that exceed the “Maximum Eligible Charge” amount are not included in satisfying the out-of-pocket maximum. 

In the above example, the $12,000 (40% participant co-insurance) would apply to the out-of-pocket maximum, but the $20,000 amount exceeding the “Maximum Eligible Charge” would not be applied to the out-of-pocket maximum.

A participant can attempt to negotiate directly with an out-of-network provider to accept the Maximum Eligible Charge fee as payment in full.  However, an out-of-network provider is under no obligation to agree to any reduction in fee, in which case the participant would owe any balance billing amounts to the provider.

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