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?

2022 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 clergy and laity

Eligible clergy and laity 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 n in-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 the Supplemental Counseling Benefit as well as mental health benefits under your medical plan 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 $1,000 annual deductible ($3,000 maximum for family coverage) before the plan begins to pay benefits.
  • 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 (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 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.
  • 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 $1,850 annual deductible amount ($3,700 maximum for family coverage).
  • Once you reach your annual deductible:
    • 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 (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 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.

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 an in-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 $1,000
Family $3,000

Individual $1,850
Family $3,700 
Combined medical and 
prescription drug deductible 

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 $4,500
                  Family $9,600 
Out-of-network Individual $62,000
No family maximum: $62,000 applies to each family member 
Applies to medical expenses only

In-network Individual $6,650
                  Family $13,300 
Out-of-network Individual $62,000
No family maximum: $62,000 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

Yes

No

Eligible to open health savings account?

No

Yes

Physician office visits

In-network $30 copay primary care doctor; $40 specialist

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

Preventive care

Plan pays 100%, no deductible, in-network. Includes lab and X-rays performed outside doctor's office.

Prescription drug benefits

RxBenefits~Express Scripts prescription drug plan

RxBenefits~Express Scripts prescription drug plan

Maternity (initial prenatal visit to determine pregnancy)

In-network $30 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

Maternity (all other services)

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

Hospital services
Before you decide NOT to use a Methodist Hospital facility, see Special Hospital Benefits

In-network Plan pays 80% after deductible

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

Emergency room (true medical emergency)

Plan pays 80% after deductible

Emergency room (nonemergency)

In-network Plan pays 80% after deductible

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

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

In-network $30 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

All other covered expenses

In-network Plan pays 80% after deductible
Out-of-network Plan pays 60% of maximum allowable 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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2022 Rate Schedule

The 2022 clergy rate schedule lists the monthly contributions paid by active clergy for the Standard PPO plan or High Deductible PPO plan.

The 2022 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.

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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 1-800-252-9653 for 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 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

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, Boon-Chapman 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, Boon-Chapman 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: An out-of-network surgeon charges $20,000 for an elective (non-emergency) surgical procedure. Boon-Chapman 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, Boon-Chapman 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 Boon-Chapman 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) – Effective 1/1/2022

New federal legislation effective 1/1/2022 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

Prime Dx – Pre-authorization and Emergency Admission Review

Some services provided by your medical plan must be pre-authorized, such as non-emergency hospitalization, pregnancy, and certain outpatient procedures.  Prime Dx is the division of Boon-Chapman which provides pre-authorization as well as admission review following emergency hospitalization.  Prime Dx can be contacted at 1-800-477-4625.

Call Prime Dx at least five days before a scheduled non-emergency hospitalization, or on the next business day following an urgent or emergency hospitalization.  Call within 30 days of physician confirmed pregnancy. 

Contact Prime Dx at least three days in advance of the following outpatient procedures which require pre-authorization:

  • Arthroscopy, Diagnostic & Surgical
  • Blepharoplasty
  • Cardiac Catheterization and/or Surgery
  • Carpal Tunnel Surgery
  • Chemotherapy – Initial treatment and/or changes to treatment plan
  • Dialysis
  • Durable Medical Equipment – Renting or purchasing if the cost exceeds $1,000
  • High Tech Radiology (included but not limited to MRIs, CT Scans and PET Scans)
  • Home Health Care
  • Hospice Care
  • Infusions or Injections for which billed charges are over $500
  • Outpatient Services performed at a Skilled Nursing Facility
  • Physical, Occupational, or Speech Therapy
  • Radiation Therapy – Initial treatment and/or changes to treatment plan
  • Septoplasty

Please review the Utilization Management Program section of the plan documents on the benefits website at Policies and Plan Documents (txcumc.org) 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-authorization is not obtained in advance, the participant runs the risk that the service may not be a covered benefit under the plan, or that the service may be determined not to be medically necessary or not to be appropriate standard of care, in which case the participant would receive no benefits under the plan and would be responsible for all charges

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