Choosing a Plan
Choosing Your Medical Plan
The Episcopal Church Medical Trust offers an array of plans through major vendor networks. Employers have the option of offering one or multiple medical plans to their employees. Employees select from the options available to them, choosing the plan that best meets their needs.
Plan Documents for Important Details
We have online resources to help you understand and use your benefits. The Summaries of Benefits and Coverage (key highlights of the plans) and Plan Handbooks (detailed explanations of coverage) are available online and are downloadable.
Also, each of our network vendors has a website with a wealth of information about its medical plans, wellness information, and how to find network providers. See Contact Information.
Questions to Consider When Evaluating Medical Plans
The first step in selecting a plan starts with understanding your medical usage, specifically anticipating what your needs will be in the coming year. Consider whether your coverage needs have changed - have you had a baby, gotten married or divorced?
Example A. You are in good health and only visit the doctor for annual check-ups and an occasional illness. You might be comfortable with a plan that has a lower monthly payment with a higher deductible and fees when you require services.
Example B. You have a condition requiring frequent doctor visits, medications, and maybe even hospitalization. You might be more comfortable with a plan that has a higher monthly premium, but lower fees and deductibles when you require services.
Look at the plans your employer is offering. Not all the Medical Trust plans are available in every region, and employers offer different options. Ask which plans are available to you.
Does your spouse have coverage that’s available to you? If so, compare that coverage to what is available through your employer to see which best meets your needs.
Once you’ve selected plans to consider, compare the Summaries of Benefits and Coverage for each. You’ll see at a glance the costs for routine doctor visits, specialist care, and hospitalization, among other details. Some of the most important items to compare include the following:
The deductible is the amount that you must pay out-of-pocket before most benefits become available. The Medical Trust has plans that offer deductibles between $0 and $7,000 for network providers. All plans have separate single and family deductibles, and all have deductibles that apply separately to network benefits and out-of-network benefits. Be sure to identify the deductible amounts that would apply to you in each of the plans.
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.
The out-of-pocket limit is the maximum out-of-pocket expense you will be responsible for during the plan year. Again, the Medical Trust’s plans have out-of-pocket amounts for single and family plans, and for network and out-of-network benefits.
Coinsurance is the percentage you pay for medical services, for example 10% of hospitalization costs. You pay coinsurance until you meet your plan’s out-of-pocket limit.
Copays are fixed amounts that members pay, for example, $30 for an office visit. Copays apply toward out-of-pocket limits, so when you reach your out-of-pocket limit for the calendar year, you will not be charged copays.
The Medical Trust’s consumer-directed deductible health plans (CDHPs) do not have copays. Members pay all medical expenses out-of-pocket, often funded by a health savings account (HSA), up to the deductible. After reaching the deductible, members pay a coinsurance amount for services. All coinsurance payments count toward the out-of-pocket limit, after which all covered medical services are provided without charge for the remainder of the plan year.
Office visits are perhaps the most common use of medical benefits. Many of the Medical Trust’s plans require a copay for office visits, with different amounts for primary care physicians, specialists, and urgent care centers. Some plans have a coinsurance payment rather than a copay for office visits.
Hospitalization, including outpatient surgery, is a significant medical expense. Most of the Medical Trust’s plans have only a coinsurance payment.
You’ll want to ensure that your preferred doctors and local facilities are in your plan’s network. To do so, you can go online to the plan’s website and use their “locate a doctor/provider” service, or call the plan for the most up-to-date information. See Contact Information.
Next, consider the process for accessing specialists, and whether this is important for you. Do you need a referral from your primary care provider before you can see a specialist (required by the Kaiser plans) or can you self-refer (typical for PPO plans)?
Another consideration many people find important is whether they can access out-of-network services and still be covered. The Medical Trust offers some plans that provide network-only benefits. These EPOs have no out-of-network coverage, except in an emergency. We also offer plans that provide out-of-network benefits, although at a lesser reimbursement than network benefits. If you want to retain the choice of coverage for services from out-of-network providers, select a PPO, OAP, or CDHP.1
The following is a list of the Medical Trust benefit plans offering only network coverage. (These plans may or may not be offered by your employer.)
- Kaiser Permanente plans (all)
The Medical Trust offers two prescription drug benefits - standard and premium. The difference between the two benefit plans is the dollar amount of copays required for medications. If your employer offers the premium benefit – which has a higher monthly premium – you will have lower copays for medications.
The CDHPs and Kaiser plans offer pharmacy benefits that differ in certain aspects from the standard and premium prescription drug coverage. Please see plan details for more information. (Please note: these plans are not offered by all employers.)
The Medical Trust’s behavioral health benefits are totally compliant with federal regulations requiring parity for physical health benefits. Members should review the copays and/or coinsurance amounts applicable to office visits and in-patient care for this benefit.
All of the Medical Trust plans offer services that do not require the deductible to be met. These include:
- Vision. Our plans have no copay for an annual eye exam with a network provider. In addition, the vision benefit, provided through EyeMed, has a small copay for lenses and contact lens fit, as well as a generous annual allowance for frames or contacts, which are not applied to the medical deductible or out-of-pocket maximum.
- Employee Assistance Program. The Medical Trust’s Employee Assistance Program (EAP), managed through Cigna Behavioral Health, is part of all of our plans. Licensed clinicians can help with almost any issue, including stress, elder care, legal/financial issues, substance use disorder, and emotional and physical health. Services are free, confidential, and available to all members of your household, even non-covered family members. The plans cover unlimited telephone consultations and up to 10 in-person visits per issue with no copay and no deductible.
- Health Advocate. This service is available with all of our plans and provides free hands-on assistance for all types of medical and administrative issues. Health Advocate can help members, their spouses, dependents, parents, and parents-in-law resolve claims issues, find doctors or hospitals, handle elder care issues, understand treatment options, find community resources, and schedule appointments with hard-to-reach specialists.
- Travel Assistance. UnitedHealthcare Global Assistance provides emergency medical and travel assistance services for Medical Trust plan members traveling at least 100 miles from their primary residence.
The Medical Trust’s plans offer many other benefits when medically necessary, such as:
- Allergy testing
- Autism treatment
- Bariatric surgery
- Chiropractic care
- Infertility treatments
- Maternity services
- Smoking cessation
Members should review the costs of the particular services that are important in their situations when comparing the Medical Trust’s plans.
What if I need more help?
As always, the Medical Trust’s Client Services team is available to assist in understanding your plan and benefits. Our representatives are available Monday-Friday 8:30AM - 8:00PM ET (excluding holidays) at (800) 480-9967 or by email at firstname.lastname@example.org .
1 The Kaiser CDHP-20/HSA is built on a managed care platform and therefore has no out-of-network benefits.
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.