You may fill your prescriptions at any Express Scripts participating pharmacy by showing your Express Scripts ID card. For maintenance medications, you are required to use home delivery after three pharmacy fills (once for the original prescription and two refills). Express Scripts' home delivery system permits up to a three-month supply of medication at once, typically at a cost savings.
The Medical Trust offers three levels of dental coverage through Cigna Dental:
- Preventive Dental PPO
- Basic Dental PPO
- Dental & Orthodontia PPO
Talk to your benefits administrator to determine which, if any, your employer offers.
Your coverage includes behavioral health benefits for individual and family needs, both inpatient and outpatient. You have access to an integrated behavioral health program that includes behavioral health, substance use disorder, and employee assistance program benefits.
A Church-wide program of healthcare benefit plans authorized by General Convention and administered by The Church Pension Fund (CPF), with benefits provided through The Episcopal Church Medical Trust (The Medical Trust).
For details, see questions about DHP below.
The price of your medication depends on whether you are purchasing a generic, preferred, or non-preferred drug and whether you are getting your medication through home delivery or at a pharmacy.
Choosing generic (Tier 1) and then preferred (Tier 2) drugs will keep costs down, along with using the home delivery prescription service. Discuss these options with your physician when you receive prescriptions.
A deductible is the amount you must pay for healthcare before a plan begins to pay.
Most of the plans offered by the Medical Trust have an embedded deductible.
- Once each member of your family has met the individual deductible, this Plan will begin to provide benefits for that individual. The individual deductible is also credited toward the family deductible. Once the family deductible has been met, all covered members of your family will receive benefits, whether or not they have met the individual deductible.
The Anthem CDHP-15 provides a non-embedded deductible and out-of-pocket limit.
- If you have single coverage, then the Plan will begin to provide benefits once you have met the individual deductible. If you have spousal or family coverage, then the family deductible must be met before the Plan begins to pay for benefits for any covered family member, and the family out-of-pocket limit must be met before the Plan begins to pay 100% for any covered family member.
A copayment is the fixed dollar amount that you pay for each healthcare service (for example, a doctor's office visit or a prescription).
Coinsurance is an amount (usually a percentage) that you may be required to pay as your share of the cost of services after deductibles have been met until you meet the out-of-pocket maximum.
My insurance is refusing to pay for a service that I believe is covered under my plan. What should I do?
Health Advocate, included in your health insurance coverage, can help you resolve insurance claims. This benefit is included in your coverage. Call (866) 695-8622 or visit the Health Advocate website.
Annual enrollment is a designated period each year when members may enroll in, or make changes to, healthcare coverage for themselves and/or their dependents. Annual enrollment usually occurs in the fall. Plan selections become effective on the first day of the following plan year.
Are there any circumstances under which I can change plans, other than during the annual enrollment period?
Yes, you may change your coverage if you experience a significant life event, such as the death of a spouse, marriage, divorce, or retirement. Keep in mind that your coverage change must be directly related to your significant life event. For example, if you get married, you may add your new spouse to your coverage.
All The Medical Trust health plans include:
- Behavioral Health/Substance Use Disorder
- Employee Assistance Program
- Vision care
- Hearing discounts
- Health Advocate
You can enroll the following dependents on your medical plan:
- Your spouse
- Your domestic partner, if elected by the participating group
- Your child who is 30 years of age or younger
- Your disabled child, 30 years of age or older, provided the disability began before the age of 25.
Adding dependents to your health plan may add to the cost. Please contact your benefits administrator for more information.
This program is available to help you with work/life balance issues. The plan covers unlimited telephone consultations and up to 10 free in-person visits with a Cigna counselor per issue. Licensed clinicians can provide resources and referrals on issues such as coping with stress, child and senior care, legal/financial matters, substance use disorder, and emotional and physical health.
The Denominational Health Plan (DHP)
A Church-wide program of healthcare benefit plans authorized by General Convention and administered by The Church Pension Fund (CPF), with benefits provided through The Episcopal Church Medical Trust (the Medical Trust).
Employers are required to provide all eligible clergy and lay employees with equal access to and parity of funding for healthcare benefits, to be provided through the Medical Trust. Under the terms of this resolution, an eligible employee is someone who is scheduled for at least 1,500 hours of compensated work annually for any domestic diocese, parish, mission, or other ecclesiastical organization or body subject to the authority of the Church.
Full implementation of the DHP was to be completed no later than January 1, 2013. The period for achieving parity in cost-sharing was extended to December 31, 2015 by Resolution B026 in 2012.While the majority of dioceses have DHP policies in place, the IBAMS Account Managers continue to consult with those dioceses that continue in the implementation process.
- Provide healthcare cost-containment for our Church by leveraging its aggregated size for large-scale purchasing of employee healthcare benefits.
- Provide dioceses and groups with control, choice, and flexibility.
- Balance financial constraints with the cost of delivering employee healthcare benefits.
- Provide equal access to healthcare benefits for all eligible employees through parity of plans and funding for the eligible clergy and lay employees of groups required to participate.
- Provide the assurance of future healthcare benefits for clergy and lay employees.
- Provide financial stability for employees through protection from catastrophic healthcare expenses and position employers to better absorb claim fluctuations and volatility.
- Decrease the healthcare benefit administrative burden for most employers.
- Provide comprehensive and integrated care management programs and processes for delivery of improved health outcomes.
- Proactively encourage the Church’s clergy and lay employees to embrace healthy lifestyles, wellness strategies, and preventive healthcare.
- Provide excellent customer service.
- Provide individualized service, support, and education to dioceses through the assignment of a Regional Relationship Specialist from the Medical Trust’s Client Relations department for each province.
As of April 2016, average Medical Trust rates were approximately 4% below the average health insurance exchange rate, and we expect the DHP’s position to improve for 2017. The Medical Trust estimates that over 90% of the groups participating in the DHP will be in a more competitive position than their local exchanges in 2017.
The Medical Trust was able to deliver a single-digit average rate increase of 5.5% for the 2017 plan year, a favorable result as compared to exchange rate increases that averaged 24%. The ongoing process of monitoring local market developments enables the Medical Trust to make necessary adjustments in future renewals to address market competitiveness issues that may continue or arise due to volatility in the exchanges.
Does the DHP require parish schools, camps and conference centers, social service agencies, and other Episcopal institutions to participate?
No. The decision as to whether or not to require the participation of other Episcopal institutions under diocesan authority will be left to each individual diocese. However, organizations that are not required to participate by the diocese can choose to do so voluntarily.
Does participation in the Medical Trust under the DHP require a group to comply with the requirements of the Lay Employee Pension System (Resolution A138) too?
The Lay Employees’ Pension System and the Denominational Health Plan are two separate canonical requirements. Although they are independent of each other, all dioceses, parishes, and missions are required to comply with each.
The Patient Protection and Affordable Care Act (PPACA) and the regulations issued under it will have significant short term and long term impacts on the health plans of the Episcopal Church. The Medical Trust remains informed on the impact to employer-sponsored health coverage, and is compliant with changing requirements as well as adapting our health plans in ways that seek to minimize disruption to our employers and our members.
The Medical Trust healthcare plans conform to many of the new healthcare reform requirements:
- Plan members are provided with 100% coverage for most preventive services recommended by the U.S. Preventive Services Task Force (USPSTF).
- Eligible members are not excluded from coverage on the basis of their individual health conditions.
- Pre-existing condition limitations are not imposed.
- Contribution rates are not determined on the basis of individual health history.
- Coverage is not canceled on the basis of individual health status.
- The Medical Trust expanded health coverage to eligible adult children and stepchildren through age 30, regardless of student status, marital status, or tax-dependent status.
- The Medical Trust health plans have no annual or lifetime maximums.
- The Medical Trust absorbed an accumulated $3.03 million in required ACA fees rather than passing these fees about to participating dioceses and institutions.
- The Medical Trust is compliant with IRS reporting (1094-B and 1095-B) to individuals and the IRS for the individual mandate.
There are ongoing provisions that may impact the Medical Trust health plans in the future. We are working with other denominations through the Church Alliance to determine how our healthcare plans may be affected in the future. We will keep you up to date as more information becomes available.
The future of the ACA is uncertain following the 2016 election results. President Donald J. Trump and congressional leadership have indicated repealing and replacing the law is a top priority. The ACA also faces instability in the state exchanges due to high premium increases and lower participation than expected. While it is too early to tell what will ultimately happen, the ACA is likely to undergo significant changes over the next few years. The Medical Trust will continue to monitor these developments and how the DHP is impacted.
Both this resolution and Resolution A138 (Lay Employee Pension System) speak to social justice issues around adequate benefits for the Church’s lay employees. While cost concerns around these initiatives are real, so is the need of lay employees to have adequate pension and healthcare benefits. The support and dedication of lay employees make many ministries possible, and providing them with adequate benefits is not only necessary, it’s the right thing to do.
Historically, there has been some inequity between lay and clergy benefit cost to the employee. Resolution A177 requires that each diocese establish a cost-sharing policy, and that it be the same for clergy and lay employees who are scheduled for at least 1,500 hours of compensated work per year.
Clergy and lay employees required to participate in the Medical Trust’s health plans are those who are scheduled to work at least 1,500 compensated hours per year for any domestic diocese, parish, mission, or for any other ecclesiastical organization or body subject to the authority of the Church (and whose diocese has determined it must participate.)
The Medical Trust’s eligibility rules relating to part-time employees currently remain the same as before the formation of the DHP. This means that clergy and lay employees of any Episcopal institution who are regularly scheduled to work between 1,000 and 1,499 hours per year are eligible to participate voluntarily.
How are hourly lay employees who are hired to work fewer than 1,500 hours per year, but who actually work and are compensated for 1,500 hours or more per year, treated regarding participation?
The requirement to participate and the eligibility to participate voluntarily in the Medical Trust Plans are governed by actual compensated hours. In this case, the employees would be required to participate because the actual hours worked total or exceed 1,500 per year.
Clergy generally know if they are full-time (more than 1,500 hours annually) or part-time (less than 1,500 hours annually) employees. Full-time clergy employed by groups required to participate in the DHP are required to participate in the Medical Trust health plans. Salaried clergy employed by groups not required to participate in the DHP and who are considered full-time are eligible to participate voluntarily. Part-time salaried clergy employed by other Episcopal entities may participate voluntarily if their employers offer health-care benefits through the Medical Trust.
Currently, non-stipendiary clergy are not eligible to participate in the Medical Trust Plans, with a few exceptions as noted in the administrative guidelines. The Medical Trust is evaluating the eligibility of non-stipendiary employees as part of a strategic project initiated in 2010. Because The Episcopal Church Clergy and Employees’ Benefit Trust (“ECCEBT”), the trust through which The Medical Trust plans are funded, is a Voluntary Employee’s Beneficiary Association (VEBA ), we must evaluate eligibility of non-employees carefully.
Non-parochial clergy employed by Episcopal institutions that offer healthcare benefits through the Medical Trust are eligible to participate if they are regularly scheduled to work at least 1,000 hours per year. Non-parochial clergy (working more than 1,500 compensated hours annually) employed by diocesan institutions may be eligible or required to participate at the option of the diocese.
Each diocese will decide individually whether or not to offer healthcare benefits to same-sex domestic partners, opposite-sex domestic partners, or both.
The DHP does not address seminarian healthcare benefits coverage. Seminaries traditionally obtain their student coverage outside of diocesan medical plans. Many Episcopal seminaries use the Medical Trust’s seminarian program.
How will former employees currently enrolled in a benefit continuation program be treated under the DHP?
Although the Medical Trust plans are exempt from the Employee Retirement Income Security Act of 1974, as amended (ERISA), we do offer an Extension of Benefits (EOB) program that will cover existing employees receiving COBRA benefits through the end date that is currently in place at the time they transition to the Medical Trust Plans. Once an employer participates with the Medical Trust, the EOB program will be available to departing employees. Those employees who left employment in 2010 or before are eligible for a maximum period of 18 months from their employment termination date. Beginning January 1, 2011, employees who leave employment will be able to extend their benefits for a maximum of 36 months from their employment termination date.
Plans, Products & Vendors
While the plans available from the Medical Trust may not be exactly the same as those currently offered by a particular group, the Medical Trust’s variety of plans should meet the needs of most employees. A copy of our current plan offerings is available upon request.
The Medical Trust currently offers three prescription drug plan options through Express Scripts. These designs work well for our groups and there are no plans to change them. As with the medical plan design, each group will choose which level of prescription drug benefit to offer its eligible employees.
For those groups that choose a regional Kaiser network plan, the prescription drug benefit is managed through Kaiser rather than Express Scripts.
No. Only medical benefits are required under the DHP. The Medical Trust does offer three dental plans using the Cigna dental network.
Can the Medical Trust provide a disruption report for any networks that are different from the ones we currently use?
We can provide you with a detailed provider access report for employee zip codes. Depending on the quality of the data available from the prior healthcare benefit provider, we may be able to provide actual provider disruption reports.
The DHP requires that each diocese establish, on a diocesan-wide basis, the minimum required employer cost-sharing policy for healthcare benefits. That means that a diocese can require employers to cover all or a portion of the contribution (premium) for employees and their families. “Parity” refers to the requirement that the diocesan policy regarding employer cost-sharing must be the same for all eligible clergy and lay employees scheduled to work at least 1,500 compensated hours per year. In other words, all clergy and lay employees who are scheduled to work at least 1,500 compensated hours per year must receive the same minimum level of funding — such as a percentage of the premium cost, a flat dollar amount, or a coverage level (i.e., single, family, etc.) — for healthcare benefits.
January 1, 2013 was the deadline for full implementation of the DHP. The deadline for parity was extended to December 31, 2015 by Resolution B026 passed at the 77th General Convention.
Does the Medical Trust have examples of canons, policies, rules, or guidelines other dioceses have created to govern the cost-sharing parity requirement?
Examples of canons/resolutions or policies that other dioceses have developed are available upon request from your Regional Relationship Specialist.
Do the parity rules apply only to clergy and lay employees hired after implementation of the DHP within the diocese? Can the diocese grandfather current employees using its current cost-sharing policies?
No. By December 31, 2015, all clergy and lay employees who are scheduled to work at least 1,500 compensated hours per year must be treated equally with regard to cost-sharing of the medical plan premiums, no matter when they were hired.
Yes. The DHP requires that all clergy and lay employees who are scheduled to work at least 1,500 compensated hours per year be treated equally with regard to the cost-share of medical plan premiums. Employers are free to provide a different cost-share to their part-time employees.
The diocese is the primary partner in implementing the DHP within that diocese. The diocese must establish canons, policies, rules, or guidelines to determine:
- Whether institutions under its authority (schools, day care facilities, social service agencies, etc.) are required to participate
- Whether the diocese wishes to provide healthcare benefits to domestic partners
- A cost-sharing policy that is the same for clergy and eligible lay employees
- Which Medical Trust plans will be offered in that diocese. The diocese makes this decision annually.
How does the diocese determine what other institutions it may require to participate with the diocese in the Medical Trust plans?
The rules governing the ECCEBT’s status as a VEBA require that only eligible employees of Episcopal institutions be allowed to participate in the Medical Trust’s plans. The Medical Trust has developed a document, “Questions to Consider When Determining if an Organization is Subject to the Authority of the Church,” to assist dioceses in determining which of its diocesan institutions are considered Episcopal institutions, according to these stipulations.
Can groups required to participate choose to purchase healthcare benefits elsewhere, especially if they can get them at a lower cost?
No, but the Medical Trust will work with all employers to find plans that are economically viable for their specific situations and populations. It is important that all required groups participate with the Medical Trust to ensure optimal leverage in negotiating services from our contracted vendors.
Participation in a Medical Trust plan is required by the canon enacted by the General Convention of The Episcopal Church and is enforced in the same manner that any canon is enforced. It is the individual diocese’s responsibility to ensure compliance with Resolution A177, as it is with all canons. The Medical Trust will not enforce compliance.
The Medical Trust has developed specific communication tools for the diocese to use for effective communications. We will work with each diocese to create a communication plan regarding the implementation of the DHP.
Before the annual enrollment period begins, the diocese should communicate specific information to its parishes and other participating institutions regarding its plan selections, associated rates, and plan design changes so that employees can make informed decisions about their specific healthcare options. During annual enrollment, the Medical Trust communicates directly with employees to provide information about how to review their plan selection choices, the resources and references available to them, and how to access the MLPS system and manage their enrollment.
(Most of the actual annual enrollment verifications and changes are done directly by the employees, using our user-friendly web-based MLPS system)
Under the terms of the DHP, clergy and lay employees who have medical benefits through approved sources will be allowed to waive medical coverage under the DHP (“opt out”) and choose to maintain their medical benefits through the approved source. Examples of approved sources include coverage through a spouse’s or partner’s employment, medical benefits through a government-sponsored program such as Medicaid or TRICARE, or coverage from a previous employer. The list of approved sources is subject to change based on the federal healthcare reform law.
An employee may elect to waive coverage at the initial point of employment, during annual annual enrollment, or at the time of any significant life event. The employee will need to reaffirm the election to waive coverage on an annual basis, as determined by the Medical Trust.
Will there be some type of form or waiver that employees are required to sign if they opt out? For those who do, will this be required annually?
Declaration of the individual waiver will occur on an annual basis during annual enrollment beginning with the enrollment for 2012. The employee will need to reaffirm the election to waive coverage on an annual basis. Each year, administrators will make sure all employee decisions to opt-out are captured properly. This data can be updated throughout the year as members join or leave the plans.
Access to providers in rural areas is a global challenge and one we continue to work to address with our national carriers BCBS, Cigna, Kaiser and UHC. These carrier networks provide 98% of members with access to a participating provider where lower out-of-pocket costs for both the member and the plan exist. In addition, we offer plans with non-network benefits that allow members to seek care from any licensed provider. We recognize that, for rural members, this often results in either extensive travel to find a participating provider or the higher costs associated with having to utilize non-network care. This is why we have engaged our plan partners in the process of seeking solutions, since they are better able to influence and engage local healthcare providers on our behalf. Geographic cost of healthcare is a factor in the pricing of groups; as overall cost efficiencies are realized, rural groups will benefit.
How does an existing Letter of Agreement (LOA) with a cleric or lay employee affect a diocese’s compliance with Resolution A177’s parity requirement?
The issue is complicated. There are several factors that may influence the relationship between an existing letter of agreement and the DHP. It is important to have your diocesan chancellor review existing LOAs to determine whether revisions to the LOAs are required and, if so, to determine the appropriate process for amending them.
The DHP does not change the Medical Trust’s current practice of providing coverage for eligible employees who retire before they are eligible for Medicare. If an employee has worked for the Church (a diocese, a congregation, or other institution under the authority of the Church) and has accrued at least five years of credited service immediately prior to retirement, that employee is eligible to enroll in any of the active medical plans offered by the diocese from which the employee retires.
No, the post-65 Medicare supplement coverage will not change because the DHP addresses only active clergy and lay employees, not retirees.
Health benefits are offered through plans maintained by Church Pension Group Services Corporation (doing business as The Episcopal Church Medical Trust), 19 East 34th Street, New York, NY 10016.
Unless otherwise noted, websites referenced herein that are outside the www.cpg.org domain are not associated with The Church Pension Fund and its affiliates (collectively, the Church Pension Group) and the Church Pension Group is not responsible for the content of any such websites.