Health Plans

You can ask for a paper copy of your Summary of Benefits and Coverage (SBC) at any time, free of charge. Go to Forms and Publications. Check the box next to the Summary you want and then click on Mail It to Me. You can also call Client Services at (800) 480-9967 Monday - Friday 8:30AM to 8:00PM ET (excluding holidays) to request a copy.

The Medical Trust can also provide an SBC in a Spanish, Chinese, Tagalog, and Navaho. Please see our Notice of Nondiscrimination policy page or call Client Services for more information.

 

To request a copy by mail, check the box next to the title and click 

Active Clergy & Lay Employee Health Plan Information - 2020

  Title What is This For? Pgs
Anthem BCBS Handbook - 2020 Handbook of plan details

107
Anthem BlueCard PPO 100 Summary 2020 Summaries of benefits

6
Anthem BlueCard PPO 90 Summary 2020 Summaries of benefits

6
Anthem BlueCard PPO 80 Summary 2020 Summaries of benefits

6
Anthem BlueCard PPO 70 Summary 2020 Summaries of benefits

6
Anthem CDHP40 HSA Summary 2020 Summaries of benefits

6
Anthem CDHP20 HSA Summary 2020 Summaries of benefits

6
Anthem CDHP15 HSA Summary 2020 Summaries of benefits

6
Cigna Handbook 2020 Plan handbook

1
Cigna Open Access Plus PPO 100 Summary 2020 Summaries of benefits

6
Cigna Open Access Plus PPO 90 Summary 2020 Summaries of benefits

6
Cigna Open Access Plus PPO 80 Summary 2020 Summaries of benefits

6
Cigna Open Access Plus PPO 70 Summary 2020 Summaries of benefits

6
Cigna CDHP40 HSA Summary 2020 Summaries of benefits

6
Cigna CDHP20 HSA Summary 2020 Summaries of benefits

6
Cigna CDHP15 HSA Summary 2020 Summaries of benefits

6
Kaiser Handbook - 2020 Handbook of plan details

106
Kaiser High EPO Summary 2020 Summaries of benefits

6
Kaiser EPO 80 Summary 2020 Summaries of benefits

6
Kaiser CDHP Summary 2020 Summaries of benefits

6
N/A Understanding Health Plan Options for Employees Age 65+ To help employers and employees understand health plan coverage options for active clergy or lay employees, or those returning to work after retirement

5
CDHP/HSA Fact Sheet for Members 2019-2020 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2019-2020

7

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Active Clergy & Lay Employee Health Plan Information - 2019

  Title What is This For? Pgs
Anthem BCBS Handbook - 2019 Handbook of plan details

118
Cigna Handbook - 2019 Handbook of plan details

110
Health-Kaiser Handbook - 2019 Handbook of plan details

120
Annual Enrollment Guide - 2019 Information about 2019 health plans and making a plan selection

26
Anthem BCBS BlueCard PPO 100 - 2019 Summary of benefits

6
Anthem BCBS BlueCard PPO 90 - 2019 Summary of benefits

6
Anthem BCBS BlueCard PPO 80 - 2019 Summary of benefits

6
Anthem BCBS BlueCard PPO 70 - 2019 Summary of benefits

6
Anthem BCBS CDHP-15/HSA - 2019 Summary of benefits

6
Anthem BCBS CDHP-20/HSA - 2019 Summary of benefits

6
Anthem BCBS CDHP-40/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 100 - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 90 - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 80 - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 70 - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-15/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-20/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-40/HSA - 2019 Summary of benefits

6
Kaiser High EPO - 2019 Summary of benefits

6
Kaiser EPO 80 - 2019 Summary of benefits

6
Kaiser CDHP-20 - 2019 Summary of benefits

6
CDHP/HSA Fact Sheet for Members - 2018-2019 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2018-2019

7
N/A Understanding Health Plan Options for Employees Age 65+ To help employers and employees understand health plan coverage options for active clergy or lay employees, or those returning to work after retirement

5

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To request a copy by mail, check the box next to the title and click 

Retired Clergy Health Plan Information - 2020

  Title What is This For? Pgs
Medicare Supplement Handbook 2020 Plan handbook

155
Medicare Comparison Chart 2020 Medicare costs and Medicare Supplement plan comparisons

2
N/A Retiree Annual Enrollment with Subsidy Letter-Sept 2019 Annual Enrollment information for retirees who receive a Medicare Supplement Health Plan subsidy

8
N/A Retiree Annual Enrollment Non-Subsidy Letter-Sept 2019 Annual Enrollment information for retirees who do not receive a Medicare Supplement Health Plan subsidy

8
N/A Medicare and You 2020 The official US Government Medicare Handbook for 2020

120
N/A Understanding Health Plan Options for Employees Age 65+ To help employers and employees understand health plan coverage options for active clergy or lay employees, or those returning to work after retirement

5

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To request a copy by mail, check the box next to the title and click 

Retired Clergy Health Plan Information - 2019

  Title What is This For? Pgs
Medicare Supplement Handbook - 2019 Plan Handbook

128
N/A 2019 Annual Enrollment-Retiree Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees

8
N/A 2019 Annual Enrollment-Retiree Non-Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees not eligible for Subsidy

8
N/A Medicare & You 2019 The official US Government Medicare Handbook

120
N/A Medicare Comparison Chart 2019 Medicare costs and Medicare Supplement plan comparisons

2
N/A Understanding Health Plan Options for Employees Age 65+ To help employers and employees understand health plan coverage options for active clergy or lay employees, or those returning to work after retirement

5

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To request a copy by mail, check the box next to the title and click 

Retired Lay Employee Health Plan Information - 2020

  Title What is This For? Pgs
Medicare Supplement Handbook 2020 Plan handbook

155
Medicare Comparison Chart 2020 Medicare costs and Medicare Supplement plan comparisons

2
N/A Retiree Annual Enrollment Non-Subsidy Letter-Sept 2019 Annual Enrollment information for retirees who do not receive a Medicare Supplement Health Plan subsidy

8
N/A Medicare and You 2020 The official US Government Medicare Handbook for 2020

120

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To request a copy by mail, check the box next to the title and click 

Retired Lay Employee Health Plan Information - 2019

  Title What is This For? Pgs
Medicare Supplement Handbook - 2019 Plan Handbook

128
N/A 2019 Annual Enrollment-Retiree Non-Subsidy Letter Announcing Annual Enrollment dates and medicare supplement information for retirees not eligible for Subsidy

8
N/A Medicare & You 2019 The official US Government Medicare Handbook

120
N/A Medicare Comparison Chart 2019 Medicare costs and Medicare Supplement plan comparisons

2

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To request a copy by mail, check the box next to the title and click 

Dental Plan Information - 2020

  Title What is This For? Pgs
Cigna Dental Handbook 2020 Plan handbook

76
Cigna Preventive Dental Summary 2020 Summaries of benefits

3
Cigna Basic Dental Summary 2020 Summaries of benefits

2
Cigna Dental & Orthodontia Summary 2020 Summaries of benefits

2

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To request a copy by mail, check the box next to the title and click 

Dental Plan Information - 2019

  Title What is This For? Pgs
Cigna Dental Handbook - 2019 Handbook of plan details

76
Cigna Preventive Dental PPO - 2019 Summary of benefits

6
Cigna Basic Dental PPO - 2019 Summary of benefits

6
Cigna Dental & Orthodontia PPO - 2019 Summary of benefits

6

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To request a copy by mail, check the box next to the title and click 

Seminarians Health Plan Information - 2020

  Title What is This For? Pgs
Anthem BCBS Handbook - 2020 Handbook of plan details

107
Anthem BlueCard PPO 80 Summary 2020 Summaries of benefits

6
Anthem BlueCard PPO 70 Summary 2020 Summaries of benefits

6
Anthem CDHP40 HSA Summary 2020 Summaries of benefits

6
Anthem CDHP20 HSA Summary 2020 Summaries of benefits

6
Cigna Handbook 2020 Plan handbook

1
Cigna Open Access Plus PPO 80 Summary 2020 Summaries of benefits

6
Cigna Open Access Plus PPO 70 Summary 2020 Summaries of benefits

6
Cigna CDHP40 HSA Summary 2020 Summaries of benefits

6
Cigna CDHP20 HSA Summary 2020 Summaries of benefits

6
CDHP/HSA Fact Sheet for Members 2019-2020 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2019-2020

7

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To request a copy by mail, check the box next to the title and click 

Seminarians Health Plan Information - 2019

  Title What is This For? Pgs
Anthem BCBS BlueCard PPO 80 - 2019 Summary of benefits

6
Anthem BCBS BlueCard PPO 70 - 2019 Summary of benefits

6
Anthem BCBS CDHP-40/HSA - 2019 Summary of benefits

6
Anthem BCBS CDHP-20/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 80 - 2019 Summary of benefits

6
Cigna Open Access Plus PPO 70 - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-40/HSA - 2019 Summary of benefits

6
Cigna Open Access Plus CDHP-20/HSA - 2019 Summary of benefits

6
CDHP/HSA Fact Sheet for Members - 2018-2019 Information for members on Consumer Directed Health Plans (CDHP) and Health Savings Account (HSA) for 2018-2019

7

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To request a copy by mail, check the box next to the title and click 

Additional Benefits

  Title What is This For? Pgs
N/A 100 Reasons to Call the Employee Assistance Program 100 Reasons to call EAP

4
N/A Employee Assistance Program (EAP) Get 24/7 help with behavioral health, family, and personal issues

2
N/A Employee Assistance Program (EAP) For Clergy For clergy to get 24/7 help with behavioral health, family, and personal issues

2
United Healthcare Global Assistance Brochure Emergency assistance available when traveling

6
N/A Health Advocate Brochure A personal health advocate service to help you with healthcare and insurance issues

6
EyeMed Insight Network EMT Brochure and Summary of Benefits EyeMed Insight Network benefits for the Episcopal Church Medical Trust

2
U.S. Medical Glossary Understand common healthcare terms

4

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Claims

Title What is This For? Contact Information
Medical Claim Form (Anthem) To submit a claim for medical expenses, or behavioral health expenses

Anthem Blue Cross and Blue Shield
PO Box 105187
Atlanta, GA 30348
International Medical Claim Form (Anthem) To submit a claim for international medical expenses

Medical Claim Form (Cigna) To submit a claim for medical expenses

Mail form with itemized bills to Cigna address on your ID Card
Medical Claim Form (Kaiser Permanente) To submit a claim for medical expenses

Kaiser Permanente Insurance Company (KPIC) Self-Funded Claims Administrator
P.O. BOX 30547
Salt Lake City, UT 84130-0547
Phone: (866) 213-3062
Dental Claim Form (Cigna) To submit a claim for dental services

For mailing address, call Customer Service at number listed on your ID Card
Colleague Group Claim Form Colleague Group Reimbursement Claim Form

The Episcopal Church Medical Trust
19 East 34th Street,
New York, NY, 10016;
or fax to (212) 251-8891
Prescription Drug Claim Form (Express Scripts) To submit a claim for prescription drugs

Express Scripts, Inc.
P.O. Box 66583
St. Louis, MO 63166-6583
ATTN: NGC STD ACCTS
Prescription Drug Claim Form (Kaiser Permanente) To request reimbursement for covered medications purchased at retail cost

Send completed form with pharmacy receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
Medicare Part D Prescription Drug Claim Form Prescription Claim Form for Medicare Part D

Express Scripts
ATTN: Medicare Part D
P.O. Box 14718
Lexington, KY 40512-4718
FAX: (608) 741-5483
Behavioral Health Claim Form (Cigna) To submit a claim for behavioral health expenses

Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422

Or follow mailing instructions on your ID Card
EyeMed Out of Network Vision Services Claim Form Out of Network Vision Services Claim Form

EyeMed Vision Care
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111
Hearing Benefit Reimbursement Claim Form Hearing Benefit Claim Form (UHC)

MAIL the Claim Form and the proof of payment attachments to:
UnitedHealthcare, Atlanta Service Center, PO Box 740827, Atlanta, GA 30374
International Travel Claim Submission Form-Medicare Supplement Plans Only Submitting international travel claims for Retirees participating in Medicare Supplement plans only

Episcopal Church Medical Trust
Travel Protection Benefit Coordinator
PO Box 2745
New York, NY 10163

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Medicare Secondary Payer (SEE) Forms

Title What is This For? Contact Information
Medicare Secondary Payer Eligibility Certification Form Eligibility for the Episcopal Health Plan for Qualified Small Employer Exception Members (the SEE Plan)

The Episcopal Church Medical Trust
19 East 34th Street,
New York, NY, 10016
or fax to (212) 251-8891

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To request a copy by mail, check the box next to the title and click 

Medicare Secondary Payer  (SEE) Publications

Title What is This For? Pgs
Medicare Secondary Payer SEE Member Fact Sheet Medicare Secondary Payer - Small Employer Exception

5
Medicare Secondary Payer SEE Letter to Members Letter sent to members explaining Medicare Secondary Payer See program

1

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Denominational Health Plan

  Title What is This For? Pgs
N/A DHP Annual Report 2019 - English 2019 Annual Report on the Denominational Health Plan

3
N/A DHP Annual Report 2019 - Español 2019 Annual Report on the Denominational Health Plan

4
N/A DHP Annual Report 2018 - English 2018 Annual Report on the Denominational Health Plan

4
N/A DHP Annual Report 2018 - Español 2017 Annual Report on the Denominational Health Plan

4
N/A DHP Annual Report 2017 - English 2017 Annual Report on the Denominational Health Plan

4
N/A DHP Annual Report 2017 - Español 2017 Annual Report on the Denominational Health Plan

4
N/A DHP Annual Report 2016-English 2016 Annual Report on the Denominational Health Plan

1
N/A DHP Annual Report 2016-Español 2016 Annual Report on the Denominational Health Plan (Español)

1
N/A DHP Annual Report 2015 - English 2015 DHP Annual Report (English)

3
N/A DHP Annual Report 2015 - Español 2015 DHP Annual Report (Español)

4
N/A DHP Annual Report (English) 2014 DHP Annual Report (English)

8
N/A DHP Annual Report (Español) 2014 DHP Annual Report (Español)

7
DHP Canon, Resolutions A177 and B026 and Model Denominational Health Plan

6

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Regulatory Notices

  Title What is This For? Pgs
Children’s Health Insurance Program (CHIP) Information Children's Health Insurance Program

3
HIPAA Notice of Special Enrollment Rights HIPAA Notice of Special Enrollment Rights

1
HIPAA Privacy Notice HIPAA Notice of Privacy Practices

4
Notice of Nondiscrimination Notice of Nondiscrimination

2
Women’s Health and Cancer Rights Act (WHCRA) Notice Women’s Health and Cancer Rights Act Notice

1

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Health News

  Title What is This For? Pgs
Health News, Spring 2018 Exploring strength in community

1
Health News, Winter 2018 Inspiration to meet your goals

1
Health News, Fall 2017 Fall colors: The changing seasons of life. Preparing for the times ahead.

1
Health News, Summer 2017 Summer wellness: what to do when the heat is on!

1
Health News, Spring 2017 Planting the Seeds for Your Tomorrow

1
Health News, Winter 2017 Being SMART about the New Year

1

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