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?
As an active clergy, you and your eligible dependents are eligible for the TAC Group Health Plan if you meet the following criteria:
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Please see Policy 102.
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Eligibility includes:
Clergy – ordained, provisional, or a licensed local pastor. (Certified lay ministers and lay supply pastors are not eligible for benefits even if appointed full-time).
You must be appointed to:
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a TAC local church or
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an eligible Extension Ministry as specified below:
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Clergy where the TAC Fiscal Office is the salary-paying unit, such as District Superintendents, Center Directors, and Associate Directors.
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Clergy appointed to a TAC Wesley Foundation.
An Extension Minister who does not fall into one of the categories designated above is not eligible to participate in TAC Group Health Benefits.
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You must receive compensation from working as a clergy at least thirty (30) hours per week designated by a 75% or 100% appointment on your Clergy Compensation:
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75% appointment – on average working between 30 and 35 hours/week
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100% appointment – on average working 40 or more hours/week
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Clergy appointed 50%, 25%, or 12.5% are not eligible for TAC Group Health Benefits.
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For student local pastors, scheduled hours of academic classes plus hours worked at the local church count toward the thirty (30) hours requirement.
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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.
As an active lay employee, you and your eligible dependents are eligible for the TAC Group Health Plan if you meet the following criteria:
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You are an employee of the TAC Fiscal Office and
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You work an average of at least thirty (30) hours per week.
Rate Schedules
The 2024 clergy rate schedule lists the monthly contributions paid by active clergy for the Standard PPO plan or High Deductible PPO plan.
The 2024 lay employee rate schedule lists the monthly contributions paid by active lay employees of the TAC Fiscal Office for the Standard PPO plan or High Deductible PPO plan.
About your medical options for active clergy and laity
Eligible clergy and laity can enroll in either the Standard PPO Plan or the High Deductible PPO Plan. Both plans:
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Provide comprehensive, high-quality care at a reasonable cost for both you and TAC.
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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 an in-network provider for care, but you'll pay less out of your own pocket if you do.
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Pay 100% of the cost of preventive and wellness care only in-network. Preventive care includes annual physical checkups, recommended screenings for your age and immunizations.
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Require pre-certification of some non-emergency inpatient hospital services and certain outpatient services.
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Are self-funded, which means the covenant community pays your claims—not an insurance company.
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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.
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:
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You pay a fixed co-pay for in-network doctor visits. In-network individual deductible is $1,000, in-network family deductible is $3,000.
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The deductible is embedded.
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Family coverage is (employee + one adult, or employee + child(ren), or employee + one adult and children). If member A reached $1,000 in claims they would then only be responsible for coinsurance going forward for member A claims. If they also cover a spouse the spouse would still pay the full amount until the spouse also reaches the $1,000 deductible. The only time an individual would not have to reach their entire $1,000 individual deductible would be if the family deductible of $3,000 is met by other members of the family.
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If enrolled in single coverage (employee only), once the employee reaches their individual deductible, the plan starts paying 80%.
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For most other services, you must first pay a $1,000 annual deductible ($3,000 maximum for family coverage) before the plan begins to pay benefits.
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The plan generally pays 80% of the cost of covered services when you see an in-network provider, and you pay 20%. If you go outside the network for treatment, the plan pays 60% of the maximum allowable charge, and you pay 40% plus any balance billing.
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Out-of-network deductible: individual $3,000, family $9,000.
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Except for emergencies, you, your doctor, or a family member need to pre-certify any inpatient hospital admissions and certain outpatient services; otherwise, the medical services may not be covered and/or medically necessary in which case the participant would be responsible for all charges.
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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 out-of--network services are much higher—you really save by going to in-network providers! The out-of-pocket maximum now includes deductibles, co-pays and co-insurance.
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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.
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.
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You pay for all medical services and prescription drug expenses out of your own pocket until you reach the combined medical and prescription drug $1,850 annual deductible amount ($3,700 maximum for family coverage).
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The deductible is aggregate.
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If enrolled in family coverage (employee + one adult, or employee + child(ren), or employee + one adult and children), everyone in the family contributes to the family deductible, and that deductible must be met before the plan starts paying 80%.
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If enrolled in single coverage (employee only), once the employee reaches their individual deductible, the plan starts paying 80%.
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Once you reach your annual deductible:
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The plan generally pays 80% of the cost of covered services when you see an in-network provider, and you pay 20%. If you go outside the network for treatment, the plan pays 60% of the maximum allowable charge, and you pay 40% plus any balance billing.
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Out-of-network deductible: individual $5,550, family $11,100.
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The plan pays 80% of your prescription drug costs, and you pay 20%.
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Except for emergencies, you, your doctor, or a family member need to pre-certify any inpatient hospital admissions and certain outpatient services; otherwise, the medical services may not be covered and/or medically necessary in which case the participant would be responsible for all charges.
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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 out-of-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.
Compare your two medical options
Covered services are mostly the same under both plans. Note your savings by using an in-network providers. Both medical plans utilize the same network of doctors and offer the same covered services. The difference is the cost-share and monthly rates.
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Standard PPO plan |
High Deductible PPO plan |
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Annual medical deductible |
In-network: Individual $1,000 Out-of-network: Individual $3,000 |
In-network: Individual $1,850 Out-of-network: Individual $5,550 Combined medical and |
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Annual out-of-pocket maximum - medical |
In-network Individual $4,500 |
In-network Individual $4,500 |
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Annual prescription drug deductible |
Individual $50 |
Included in annual combined medical and prescription drug deductible (above) |
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Annual out-of-pocket maximum – prescription drugs |
Individual $2,000 |
Included in annual combined medical and prescription drug out-of-pocket maximum (above) |
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Annual maximum benefit |
None |
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Yes |
No |
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Eligible to open health savings account? |
No |
Yes |
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Physician office visits |
In-network $25 copay primary care doctor; Out-of-network Plan pays 60% of maximum allowable charge after deductible |
In-network Plan pays 80% after deductible Out-of-network Plan pays 60% of maximum allowable charge after deductible |
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Preventive care |
Plan pays 100%, no deductible, in-network. Includes lab and X-rays performed outside doctor's office. |
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Prescription drug benefits |
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Maternity (initial prenatal visit to determine pregnancy) |
In-network $25 copay Out-of-network Plan pays 60% of maximum allowable charge after deductible |
In-network Plan pays 80% after deductible Out-of-network Plan pays 60% of maximum allowable charge after deductible |
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Maternity (all other services) |
In-network Plan pays 80% after deductible |
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Hospital services |
In-network Plan pays 80% after deductible Out-of-network Plan pays 60% of maximum allowable charge after deductible |
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Emergency room (true medical emergency) |
Plan pays 80% after deductible |
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Emergency room (nonemergency) |
In-network Plan pays 80% after deductible Out-of-network Plan pays 60% of maximum allowable charge after deductible |
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Mental health (inpatient care) |
In-network Plan pays 80% after deductible |
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Mental health (outpatient care) |
In-network Plan pays 80% after deductible |
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Mental health (office visit) |
In-network $25 co-pay Primary Care or $40 co-pay Specialist; then plan pays 100% Out-of-network Plan pays 60% of maximum allowable charge after deductible |
In-network Plan pays 80% after deductible Out-of-network Plan pays 60% of maximum allowable charge after deductible |
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All other covered expenses |
In-network Plan pays 80% after deductible |
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TELADOC
Teladoc
® is a telehealth medicine program that gives participants access to quality medical care via phone access 24 hours a day, seven days a week, 365 days a year. The doctors in this program are U.S. Board Certified in Internal Medicine, Family Practice, or Pediatrics. They average 15 years’ practice experience, are licensed in your state, and incorporate Teladoc® into their day-to-day practice to provide members with convenient access to quality medical care. Teladoc® physicians can treat many medical conditions such as cold and flu symptoms, allergies, bronchitis, skin problems, respiratory infections and sinus problems, and can prescribe medications for short-term conditions.
To access this program, either visit www.teladoc.com or call 1-800-Teladoc (835-2362).
Teladoc Fees:
General Medical Visit Fees:
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High Deductible PPO Plan: $54 fee per visit until the deductible is met, then 20% co-insurance
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Standard PPO Plan: $0 co-pay
Mental Health Visit Fees:
- High Deductible PPO Plan:
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$95 for a licensed therapist visit per visit until the deductible is met, then 20% co-insurance
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$235 for an initial visit with a psychiatrist
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$105 for ongoing visits with a psychiatrist until the deductible is met, then 20% co-insurance
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Standard PPO Plan: $0 co-pay
Dermatology Visit Fees
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High Deductible PPO Plan: $85 per visit until the deductible is met, then 20% co-insurance
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Standard PPO Plan: $0 co-pay
See the current Teladoc Fee flyer for more details.
Finding in-network PPO providers
UnitedHealthcare is the PPO network. Provider information can be found UnitedHealthcare. See UnitedHealthcare In-Network Instructions for more details.
Apta Health Care Coordinators
We have chosen Apta Health to bring amazing benefits that are usually reserved for Fortune 500 Companies to its employees. Care Coordination is at the heart of our program. This unique approach to healthcare allows you access to a real, live person to talk to about your health concerns and is available completely free of charge whenever you need help. Think of your Care Coordinators as healthcare warriors that will fight for you to make sure you get the best care possible!
Available Monday through Friday, 7:30 AM to 9:00 PM by calling 1-877-610-8817. You can call them for anything from replacing a lost ID card, to help finding an in-network physician, to help with an upcoming medical procedure, and questions or issues with your medical bills.
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See Welcome Flyer from Apta Health for more details.
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See also the Get Started with Apta Health!
Apta Health – Pre-Certification and Emergency Admission Review
Some services provided by your medical plan must be pre-certified, such as non-emergency hospitalization and certain outpatient procedures. A $500 penalty will be applied for all services that do not have a pre-certification completed.
Call Apta Health at least five days before a scheduled non-emergency hospitalization, or on the next business day following an urgent or emergency hospitalization.
Contact Apta Health at least three days in advance of the following outpatient procedures which require pre-authorization:
- Oncology Care and Services
- Chemotherapy – Initial treatment and/or changes to treatment plan
- Radiation Therapy – Initial treatment and/or changes to treatment plan
- Dialysis
- Durable Medical Equipment – Renting or purchasing if the cost exceeds $1,500
- High Tech Radiology (included but not limited to MRIs, MRA's and PET Scans)
- Home Health Care
- Hospice Care
- Outpatient Services performed at a Skilled Nursing Facility Admission
- Colonoscopies
- Out-Patient Surgeries
- Genetic Testing
- Transplants - Organ and Bone Marrow
Please review the Utilization Management Program section of the plan documents on the benefits website at Policies and Plan Documents for specific information regarding pre-authorization and emergency admission review requirements.
Medical services requiring pre-authorization can be authorized after the fact; however, when pre-certification is not obtained in advance, the participant runs the risk of a $500 penalty.
Out-of-network participant liability
When you use an out-of-network provider, there are no PPO discounts. An out-of-network provider can charge any amount they choose for their services except under certain situations such as emergency care (please see the following Surprise Billing Section). For this reason, it is not recommended that you use an out-of-network provider for non-emergency services unless you are fully aware of the cost of services in advance.
Because in most cases there is no limit to what an out-of-network provider can charge, UMR as our plan administrator will determine a “Maximum Allowable Charge” (MAC) amount for services provided by an out-of-network provider. After your deductible is met, UMR will pay 60% of the Maximum Allowable Charge (MAC) amount for the out-of-network provider’s services, and you will owe 40% of MAC (your co-insurance).
In addition, if there is a difference between the Maximum Allowable Charge amount and the total amount of billed charges, you will owe 100% of the difference between MAC and the billed charges, which is called balance billing.
Example:
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An out-of-network surgeon charges $20,000 for an elective (non-emergency) surgical procedure.
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UMR determines that the MAC for the surgery is $10,000. The plan pays 60% of The $10,000 MAC or $6,000. You would owe 40% of MAC or $4,000 plus the $10,000 difference between the $10,000 MAC amount and the $20,000 total fee the out-of-network provider is charging.
In this example, UMR would pay $6,000 and you would owe a total of $14,000.
Note: Expenses that exceed the Maximum Allowable Charge amount are not included in satisfying the $50,000 individual out-of-network out-of-pocket maximum expense limit.
In the above example, the $4,000 (your 40% participant co-insurance) would apply to your $50,000 out-of-network out-of-pocket maximum expense limit, but the $10,000 amount exceeding the MAC would not be applied to your out-of-pocket maximum expense limit.
If you need to utilize an out-of-network provider for any type of elective (non-emergency) service, it might be advisable to ask if the provider will accept the MAC amount determined by UMR and not subject you to balance billing if the billed charges exceed MAC. It would be best to receive that agreement in writing from the out-of-network provider in advance of receiving any services.
Protection Against Surprise Medical Bills (Balance Billing)
New federal legislation protects you against balance billing from an out-of-network provider or facility for emergency care. This means you cannot be balanced billed (charged more than your in-network PPO rates) for emergency care provided by an out-of-network provider (ER doctor, anesthesiologist, surgeon, etc.) or by an out-of-network facility such as a hospital.
In addition, you cannot be balance billed for non-emergency, elective services (for example, a non-emergency surgery, MRI or CT scan) at an in-network hospital or ambulatory surgical center performed by out-of-network providers (such as assistant surgeons, anesthesiologists, radiologists, etc.) that are contracted directly by the in-network facility.
For further information, please review the full notice regarding Your Rights and Protections Against Surprise Medical Bills.