Outside the state of Ohio, if a Plan participant goes to a hospital for treatment, the claim would be paid as if the providers were In Network. If a participant visits a doctor’s office, the claim would be subject to the Non Network provisions.

No, the ‘wellness’ benefits of the Plan have not changed. Services such as routine physical examinations, routine pap tests, mammograms, and prostate tests are all payable at 100% of Reasonable and Customary charges, regardless of In/Out Network providers.

For Active participants: $3,600 per individual and $7,200 per family is the maximum out of pocket for non network providers.

For Retirees less than 65: $2,400 per individual and $4,800 per family is the maximum out of pocket for non network providers.

No. Dental benefits are not subject to PPO provisions.

Transition period is approximately three months starting with the introduction of a new PPO. This is for participants who are currently in the course of treatment for a “health care crisis.”

Patients in “health care crisis” can be described as those participants who have been diagnosed with a severe disorder or illness and by the treatment that is being rendered currently. For example: a cancer or leukemia patient who is undergoing chemo or radiation therapy; a current heart attack patient that is in rehab; a diabetic patient who is currently undergoing treatment for eye complications.

The course of treatment may be longer than three months. Klais & Company and the Conference Benefits Office will be available to help with these concerns.

Please note: if a person has been diagnosed, but is seeing a physician for periodic maintenance visits to monitor the condition, this care will not fall under the transition period process.

Please contact the Conference Benefits Office for Physician Request Form. Complete the form and return to the address provided. It is through negotiations between the doctor and Medical Mutual of Ohio (MMOH) that a physician becomes a preferred provider in MMOH Super Med PPO network.

Contact the Conference Benefits Office for assistance. It may be possible to run a Geo-access report. A participant may not have access to a preferred provider within a certain mile radius, but within a few more miles, preferred providers could be accessible.

Please note: the Churches of the Conference needs the support of all health care participants to do their best to take advantage of the discounts that the PPO does provide the Health Care Plan.

No. If Medicare is your primary payer, then you are not a participant subject to the PPO provisions. Your benefit limits are:

Deductible $200 (S)/$400 (F)

Co-Insurance 90% - 10%

Out-of Pocket $500 (S)/$1,000 (F)

Out of Pocket with deductible $700 (S)/$1,400 (F)

Yes. She needs to use In-Network providers in order for her claims to be paid at 90% after the deductible is satisfied. If she chooses to go to Out of Network providers, her claims would be paid at 75% after a higher deductible is satisfied.

Since you live outside the boundaries of Ohio, Outside of Ohio, Out of Area (OO-OOA) plan provisions will apply.

Deductible $200 (S)/$400 (F)

Co-Insurance 90% - 10%
Out-of Pocket

Out of Pocket with deductible $700 (S)/$1,400 (F)

The Conference plan is a comprehensive Major Medical plan whereby payment will be made for eligible medical expenses which are incurred due to accidental bodily injury, sickness or pregnancy while covered under the Plan. A Schedule of Benefits follows:

Services payable at 100% of reasonable charges (UCR), include the following:

Outpatient surgery

Pre-Admission testing

Hospital Emergency room or Urgent Care Facility charges for accidental bodily injury within 72 hours of the accident.

Second Surgical opinion

Supplemental Accident - payment of all medical expenses resulting from an accident. Payment is limited to $500 for expenses incurred within 90 days from date of accident.

Routine Annual Physical Examinations-$150 per calendar year for participant and spouse

Well child care

Home Health Care

Hospice (see Plan Document for limits)

Annual cancer screening tests (see Plan document for guidelines)

All other eligible charges are subject to the deductibles and co-insurance provisions of the Plan. Reference your Summary Plan Booklet.

Dental Coverage

All active participants, spouses, and their children, also retirees and spouses less than age 65, who are covered underthe EOC Health Care Plan are will automatically enrolled in a Preventive Basic Dental Plan. This benefit became effective November 1, 1998.

Covered Benefits: Oral Examinations, Dental Prophylaxis, Fluoride Treatment, Sealants, Space Maintainer, Dental x-rays, and Emergency Palliative Treatment.

Expenses NOT covered: Any non-preventative procedures such as: Braces, bridges, caps, crowns, dentures, fillings, periodontics, restoration, and root canals.

Amount of coverage: Eligible expenses are subject to UCR (usual, customary and reasonable). Participant Liability will be a co-payment of $15.00 per patient, per visit to the dentist. (Multiple preventative procedures can be rendered at one visit for the single co-payment of $15.00.) i.e., exam, x-rays, cleaning and fluoride treatment, all preformed during the same visit.

How to file a claim: Make an appointment with the Dentist of your choice. Obtain a Dental form from Klais & Company, Inc., or the Conference Benefits Office. Keep your appointment and present the form. The Dental Office will verify coverage with Klais & Company, Inc., and render services. Your payment of $15.00 for preventative procedures will be made at the Dentist Office. Most Dental Offices will submit the claim for the patient and receive payment for the balance of cost, directly from Klais & Company, Inc. A discussion with your Dentist’s Office concerning your Dental Benefits and the Dental Office’s payment requirements prior to the appointment is always helpful.

Hospital Admissions

The plan requires certification by INTRACORP for all Non-Emergency and Emergency Hospital Admissions and 24 Hour Observation Hospital stays. A penalty of $100 will be applied to the Hospital confinement if a call is not made. Refer to your Employee Benefit Plan Booklet and question #28 for more information.

Pre-Admission Certification

Call INTRACORP at 1-800-348-1313

Pastors under Episcopal Appointment by the East Ohio Conference are eligible to participate in this plan. You are also eligible if you are a full-time employee directly employed by the East Ohio Conference of the United Methodist Church, local church, or district. You are considered a full‑time employee under the Plan if you normally work at least 20 hours a week on an annual basis.

Reference the Board of Pensions report: Section II.C.2, concerning mandatory coverage for clergy.

A new pastor/employee who is enrolled will be covered on the date they begin active, full-time employment. A properly completed enrollment form must be received by the Conference Benefit’s Office.

You may cover your spouse and all your unmarried dependent children under age 23. In addition, your unmarried grandchildren, nieces and nephews may be covered if they reside with you and are dependent on you within the meaning of the Internal Revenue Code.

Your unmarried dependent children of any age who reside with you are eligible for coverage if they are incapable of self-support by reason of mental or physical handicap, which commenced prior to age 23.

Newborns will be covered from the moment of birth. A record change form must be submitted to Conference Benefit’s Office after the birth will enroll the newborn. This is to be handle within 31 days from birth to ensure coverage and prompt payment of the charges incurred. Adopted children are eligible for coverage the day they enter the home, provided the proper enrollment is submitted through the Benefit’s Office.

Clergy Retiree Health Care Benefits are provided if all of the following criteria is met;

a. Clergy must meet the provisions of the Discipline, Paragraph 359.2b (early retirement, age 62 or 35 years of service) or 359.2c (full retirement, age 65 or 40 years of service) (Retiree health care is NOT provided for those retiring under the 20 year rule, Paragraph 359.2a.)

b. Must be a member of the East Ohio Conference immediately preceding retirement.

c. Must be enrolled in the Conference Health Care Plan prior to age 65, or at time of retirement at any age.

d. Retirees who have twenty-five (25) or more accumulative years of pension credit service funded by the East Ohio Conference will pay 30% of their health care premiums. For service less than twenty-five (25 accumulative years, the retiree will pay 30% plus 2.8% for each year less than 25 years. (Example: a retiree with fifteen (15) years of service will pay 58% of the premium.

Your eligibility shall terminate upon date of termination of appointment/employment.

Your dependents shall remain eligible until termination of your eligibility, loss of their dependent status, (such as marriage, reaches age 23, joining the service, or becoming covered under a work plan), whichever occurs first.

Klais & Company, Inc., administers the COBRA provision of the Plan, which is continuation of health care coverage for the East Ohio Conference Health Care Benefit Plan. Circumstances in which Health Coverage terminates, an Eligible Associate or Eligible Dependent may elect to continue benefits under this Plan, at the Covered Person's own expense. Events such as employment termination, overage dependent, divorce and legal separation would qualify a person for this provision. For more details on qualifying events or any questions please contact the Benefits Office at the Area Center.

Changes are not made automatically. You are fully responsible to report any change in family status to the Benefits Office within 30 days of such change. Failure to do so may result in a lack of coverage for your dependent.

Yes. We encourage members to undergo examination by a physician every year by reimbursing up to $150 each (not subject to deductibles) of the cost of an annual physical examination for members and their spouses per calendar year. Any additional expenses over $150 will be eligible for reimbursement after the deductible. The services rendered must be for a routine examination in which the services are in the absence of patient complaints. No special form is required. If the bill provides a condition/diagnosis or procedures which are not appropriate for a routine physical without patient complaints, the charges become subject to the deductible and paid accordingly.

In addition, charges for periodic review of a child’s physical and emotional status performed by a Physician or by a health care professional under the supervision of a Physician. Such periodic review charges will include coverage for a history, complete physical examination, developmental assessment, anticipatory guidance and laboratory tests that are not treatment for an illness or injury.

Benefits for the above charges will be provided to a child during the period from birth to age two (2). Benefits for the above charges that are provided to a child during the period any year thereafter from age two (2) to age nine (23) shall not exceed a maximum limit of $150 per calendar year.

Yes. the following shall be a first dollar benefit, i.e. paid at 100% UCR, not subject to the deductible:

a. Routine diagnostic test and examination included in pap testing, one per calendar year.

b. One proctologic examination (including Prostate Antigen Blood Test) for all covered persons age 40 and older, one per calendar year.

c. Examination, including one baseline mammogram for all covered persons between the ages of 35 and 39, per calendar year, one mammogram every two years for all covered persons 40-49, and one mammogram per calendar year for covered persons age 50 and older.

d. Immunizations from birth to age two (2). Benefits for immunizations for children between from age (2) to age twenty-three (23) are limited the $150.00 and are inclusive of covered expenses as stated in question number 11.

Yes, when you are admitted as a bed patient to a hospital or when sent to an outpatient or emergency room, x‑ray and lab work is covered if directed toward a definite condition or injury. These services are covered in conjunction with a routine physical examination provided charges do not exceed the total allowable amount for physical examination. A copy of the diagnosis must accompany all claims. If these tests are part of pre-surgical testing, they are not subject to the annual deductible and are payable at 100% UCR.

Yes. $100 co-pay applies for ER treatment if not Sudden & Serious.

Emergency room visits that are for life-threatening conditions such asthma, chest pains and high fevers (104 degrees or greater) are considered as “Sudden & Serious” conditions and the claims are subject to the yearly deductible and co-pay.

Emergency room visits that are not for life-threatening conditions such as coughs and low-grade fevers are subject to $100 ER co-pay, the yearly deductible and co-pay.

Emergency room visits that are for Accidental Injury and treatment is rendered within 72 hours, are payable at 100% of reasonable & customary and not subject to deductible and co-pay.

Basic dental coverage only, reference question #11, also there is dental coverage for accidents. For questions regarding eligible expenses, please call Klais & Company.

Unmarried children are covered to age 23, regardless of whether or not they attend school, but must be your IRS dependent.

Yes. Under the COBRA provision of the Plan, when a dependent ceases to be a "dependent child" under this Plan, you may continue coverage for up to 36 months or until your dependent becomes covered under another group plan and this will be an individual plan for that child. You will send the premium directly to Klais and Company, Inc. Checks are made payable to the East Ohio Conference of the United Methodist Church.

Yes, the plan covers both mother and infant.

Non-Emergency Hospital Admission - requires at least 72 hours notice prior to the admission (but no more than 30 days prior to the estimated date of confinement).

Emergency Hospital Admission - requires notification to Intracorp by the next business day following the day of admission. The Covered Person, the Covered Person’s Physician, a member of the Covered Person’s family, or an authorized Hospital staff member can make this call. 24 Hr. Observation Admissions - require notification to Intracorp, the same as a Emergency Hospital Admission.

Claims are mailed by the hospital, directly to Klais & Company, Inc. It is important that you request an itemized bill so that you can check charges to see that they are correct.

Using In-Network providers eliminates paper work for you. The network provider will file your claims directly with Klais & Company. A claim form may be necessary if you use a Non-Network provider and you must file with Klais yourself. Claims forms are available in the Conference Benefits Office. Submit your form with an itemized bill. New updated claims are normally required each calendar, per family member covered as they incur charges. This is to verify address, status, etc.

If you are an active clergy person, please contact the Conference Benefits Office immediately.

If you are retired: Contact your local Social Security Office within 6 months prior to age 65, if you are not drawing benefits from Social Security. Medicare enrollment is prompted by Social Security participation. When you become entitled to Medicare, you must be enrolled in Part A and Part B, but DO NOT enroll in Medicare D if you participate in the Conference Health Benefit Plan as a retiree.

Please send a copy of your Medicare card to the Conference Benefits Office.

Federal law requires providers to send bills to Medicare for you. Medicare will send you an Explanation of Medicare Benefits form known as an EOB. The form details how Medicare processed a claim. Make a copy of the EOB, then obtain an itemized billing from the provider and mail the EOB and the itemized bill to Klais & Company.

Medicare primary participants may complete a Klais & Company Medicare Crossover form. This option allows Klais & Company to receive Medicare claims data electronically from Medicare, allowing Klais to process retiree claims as secondary payer.

If you are an active clergy person, contact the Conference Benefits Office immediately.

If you are retired: The Conference’s Health Care Benefit Plan will become your secondary carrier. Medicare becomes your primary payer of your health care coverage. Medicare will be taking the primary financial responsibility from the Conference and the Conference’s plan will coordinate benefits as a secondary carrier.

Your eligible dependent(s) will continue coverage under the plan as they had prior to you becoming eligible for Medicare.

If you are an active clergy person, contact the Conference Benefits Office immediately.

If you are retired: The Conference’s Health Care plan will become the spouse’s secondary carrier. Medicare becomes the primary payer of health care coverage. Medicare will take the primary financial responsibility from the Conference and the Conference’s plan will coordinate benefits as a secondary carrier.

When the Conference’s Plan benefits are secondary, benefits will be paid to the extent of the difference between the benefit amount under both Parts A & B of Medicare and the dollar amount of benefits that would have been paid under the Plan had the person not become eligible for Medicare.

A secondary policy provides coverage to the limits of the plan and then subtracts the primary carrier payment (if any). The Plan will determine what it would have paid had it been primary, and reduce its benefit by whatever the Primary plan paid.

A supplemental policy provides payment by adding to the payment by Medicare, generally paying the bill in full.

Call the Conference Benefits Office at 1-800-831-3972 ext 103, if you or your spouse have reached age 65 and you are actively serving a church.

You may contact Klais & Company, Inc., for assistance with any claim. An appeal of a claim following an explanation from Klais & Company, Inc. may be directed to the Insurance Committee, Conference Board of Pensions, c/o Conference Benefit’s Office.