welcome packet the austin stone community church health ... · the austin stone community church...
TRANSCRIPT
REVISED 11/10/2017
Welcome Packet
The Austin Stone Community Church
Health & Wellness Plan
Effective January 1, 2018
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Table of Contents
Health Reimbursement Arrangement (HRA)
Common HRA Eligible Expenses
Procedure for HRA Eligible Expenses
Benefits Card Substantiation
Reimbursing the HRA
Prescriptions
Limitations
Chiropractic Care
Vision Expenses
Ambulance Services Limitations
HRA FAQ
Christian Healthcare Ministries (CHM)
Common CHM Language
Procedure for CHM Eligible Expense
Emergencies
Advance Request
CHM Frequently Asked Questions
CHM Member Portal Instructions
CHM Required Forms
Initial Member Portal Setup
Submitting Needs in the Member Portal
Submitting Add-On Bills
Maternity Instructions
Maternity Medical Bills CHM Shares
Maternity Medical Bills Covered by HRA
Maternity Expenses not Covered by Plan
OB/GYN Prepayment Agreement
Hospital Prepayment Agreement
Anesthesiology Charges
Birthing Center/Home Birth
CHM Maternity Contact
HRA Depletion
Out-of-Pocket Amounts
Keeping Track of Out-of-Pocket
Health Fund
Preventive Care
Preventive Care Benefits for Adults
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Preventive Care Benefits for Women, Including Pregnant Women
Preventive Care Benefits for Children
Contact Information
Christian Healthcare Ministries (CHM)
Employee Benefits Corporation (HRA)
ASCC HR
Additional Benefits
Teladoc Account Set Up
Dental
Vision
General Plan FAQS
Common Ineligible Plan Expenses
Appendix
EBC Quick Reference Guide
Submitting a Claim Online with EBC
Letter of Explanation Form Example
Needs Processing Form Example
Needs Processing Worksheet Example
Medical Release Information (HIPAA-compliant) Form Example
Doctor’s Office Itemized Bill Example
Health Imaging Itemized Bill Example
Lab Testing Itemized Bill Sample
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Health Reimbursement Arrangement (HRA)
The Health Reimbursement Arrangement (HRA) is first dollar coverage funded by ASCC and is used
for expenses under $5001. Your HRA will be fully available beginning on January 1 for current staff or
your hire date for new staff.
Employee Only: $1,200 | Employee + Spouse: $2,250 | Employee + Family: $4,500
The below chart explains the pieces that are involved to accessing your HRA dollars.
Additional instructions can be found in the Appendix, EBC Quick Reference Guide and Submitting a
Claim Online with EBC.
1 There are specific eligible expenses that are over $500 that are covered by the HRA. Common expenses include immunizations and routine,
maintenance prescription.
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Common HRA Eligible Expenses
● Under $500:
○ Doctor visits
○ Prescription medications
○ Maintenance medications
○ Medications prescribed for incidents that do not exceed $500
○ Immunizations and Vaccinations, even if over $500
● Chiropractic Care, limitations apply
● Vision expenses, limitations apply
● Ambulance Services, limitations apply
Refer to ASCC Health Reimbursement Account Plan, for any additional exclusions or limitations that
may apply. For a complete list of exclusions and limitations please see ASCC Health Fund document.
Procedure for HRA Eligible Expenses
At the provider’s office: 1. Communicate you are a private pay patient and would like a private-pay discount (or the cash
discount). 2. Use your Benefits Card to pay for the eligible expense. 3. Obtain an itemized bill for your records. 4. IF you need to submit the itemized bill to EBC for substantiation, EBC will contact you via email.
Benefits Card Substantiation
You may be asked to document your Benefits Card purchases by providing itemized expense
documentation. Do not submit documentation until it is requested. EBC will notify you via email of the
transactions that were not substantiated at the point of sale and need documentation submitted2. The
documentation needs to include:
1. Date of Service
2. Type of Expense
3. Amount of Expense
4. Name of Service Provider
You can go about providing the documentation to EBC two ways:
1. You can log into your account at EBCflex.com and upload documentation through the website.
2. You can use the EBC My Mobile Account Assistant app to take a picture of your documentation.
Reimbursing the HRA
The HRA should only be used for eligible expenses. If you use your HRA to pay for an ineligible
expense (i.e., something our plan does not cover), you must return the money back to your HRA within
the same plan year.
2 If you do not provide the documentation in a timely manner, your Benefits Card will be suspended and will not be activated again until
documentation is received. You will be asked to and must repay the expense amount if you make a purchase with the card and, upon request, cannot provide itemized expense documentation for the expense for any reason.
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Download the GoodRx app for a convenient way to have access to prescription
discounts!
Cost Saving Tip: For maintenance prescriptions, have your
doctor write a prescription for a 90-day supply. In most cases, you can save
money and time.
You should never be reimbursed twice for the same medical expense. If you paid for a medical
expense from your HRA and were later reimbursed by CHM for the same expense, you must also
return the money back to your HRA as soon as it’s practical to do so.
Reimbursement can be done two ways:
1. You can mail a reimbursement check to EBC at P.O Box 44347, Madison, WI 53744. With the
check, include the account holder’s first name, last name, and last 4 digits of social security
number.
2. Ask the provider if they can refund your Benefits Card. Note: It can take up to 6 weeks to see
the refund on EBC website.
Prescriptions
A majority of the prescriptions will be covered by the HRA. The only time prescriptions will be covered
by CHM is if they are part of an over $500 incident. GoodRX.com is a free resource that will help you
find the cheapest pharmacy to purchase your prescription at.
At the pharmacy, communicate:
1. You are a private-pay patient.
2. Pull up the GoodRX app on your phone and put in the prescription and dosage.
3. Select the correct pharmacy. 4. Show coupon/discount code to the pharmacist. 5. Pay for the prescription with your Benefits Card. 6. Keep a copy of receipt for your records.
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Limitations3
Chiropractic Care
Chiropractic care means any services, care or provision of medical care items provided by a licensed
chiropractor regardless of how the service is billed. For example, Airrosti©, although billed as physical
therapy, is still performed by a chiropractor. Therefore, Airrosti© visits should stay within the limits
described. Chiropractic limitations, per family, per year, are:
Employee Only: $500 | Employee + Spouse: $750 | Employee + Family: $1,000
Vision Expenses
Vision insurance is offered as an optional benefit to employees and dependents (vision plan summary)
and should be used prior to using your HRA. If you did not elect vision insurance, the HRA will cover
one annual eye exam per covered individual and benefit period, including eye health examinations,
dilation, optical mapping services, and refraction for contacts or glasses provided by an optometrist or
ophthalmologist. In addition, the HRA will cover up to $100 per covered person for purchase of glasses
or contacts.
Ambulance Services Limitations
In conjunction with the applicable Health Fund, the HRA plan will not pay for or authorize payment for
ground ambulance transportation in excess of $1,000 per family, per year and will not pay for or
authorize payment for air ambulance transportation in excess of $3,000 per year. Ambulance services
(ground and air) are not covered by CHM (unless they meet specific standards4).
3 The employee is responsible for keeping track of the limits. The HRA will not do it automatically. By electing to use our plan for these
expenses, you are committing to keep up with the limitations. 4 CHM shares bills for ambulance service from one hospital to a second one if:
● You are in a life-threatening situation (as determined by doctor reports and medical records) ● The first hospital cannot adequately treat you, so you’re transferred to a second hospital. ● The second one is the closest hospital able to provide the necessary treatment.
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HRA FAQ
Q: Is my HRA account linked with CHM?
No. These two are separate components of our plan.
Q: What do I do if my Benefits Card gets suspended?
If your card had been suspended due to not providing appropriate documentation, you can call EBC’s
Customer Service number (1-800-346-2126, option 1) and request the card be reactivated for two
weeks to allow time to gather the appropriate documentation. Once the appropriate documentation has
been provided, the card will automatically be unsuspended.
Q: What if I have another eligible HRA expense while my card is suspended and I am waiting for
the appropriate documentation?
You can pay for the eligible HRA expense with your personal card and then submit for a manual
reimbursement through EBC’s website or EBC’s mobile app.
Q: What if I am unable to provide the appropriate documentation to EBC?
You will be asked to and must repay the expense amount if you make a purchase with the card and,
upon request, cannot provide itemized expense documentation for the expense for any reason. To
reimburse your HRA, follow the reimbursing the HRA instructions.
Q: I only received one Benefits Card in the mail. Can I get another one?
Yes, you are able to order another one. Instructions on how to request additional cards are below:
1. Log on to EBCFlex.com.
2. Click the Menu button in the top left hand corner.
3. On the menu, select “Secondary Benefits Card” under the manage section.
4. Click Add.
5. Enter in dependent’s first and last name.
6. Click Add.
7. A line should come up with your dependent’s first name, last name, and the date your requested
to show that the request has been made.
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IMPORTANT:
You should not use your HRA to pay for a CHM eligible expense. If you accidentally use your
HRA for a CHM eligible expense, please refer to the section on how to reimburse your HRA to
avoid tax implications.
Christian Healthcare Ministries (CHM)
Christian Healthcare Ministries (CHM) is a health care cost-sharing ministry. CHM shares 100 percent
of all eligible medical expenses over $500 total cost to an unlimited amount. A representative, non-
comprehensive list of eligible expenses and ineligible expenses are provided below.
CHM Eligible Expenses (over $500 total cost) A representative, non-comprehensive list:
● Abdominal pain ● Hernia repair
● Accidental ingestion of harmful substances ● Hypertension
● Back problems (excluding chiropractic) ● Infections
● Blood problems and disorders ● Injuries from accidents (except self-inflicted)
● Broken/fractured/dislocated/sprained bones ● Kidney stones
● Cancer/biopsy ● Lung, liver, kidney, and pancreas problems
● Carpal tunnel ● Maternity and complications
● Cataract removal ● Medical Equipment5, necessary to sustain life
● Diabetes ● Medically necessary reconstructive surgery
● Diagnostic imaging (MRI, CAT scan,etc.) ● Neurological disease
● Diverticulitis ● Pneumonia/influenza
● Endoscopy, colonoscopy, etc. ● Podiatry
● Female health issues ● Replacements (hip, knee, shoulder, etc.)
● Gallbladder ● Stroke
● Gastrointestinal ● Ulcers
● Heart/cardiovascular ● Urology
5 Medical equipment must be prescribed by a doctor. Sleep apnea equipment prescribed by a doctor is not
eligible for sharing.
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Example:
After an appointment with the doctor for chronic headaches, Jane’s doctor has her get an MRI, CT scan, and blood work (all within a month). Once testing is completed, Jane receives an itemized bill from her doctor, the lab, the imaging place, and the pharmacy for $3,075.75 total cost. She receives a total of $1,712.25 private-pay discounts which brings her total down to $1,430.75. Since this is one incident, Jane submits the needs to CHM via the member portal. CHM shares the needs and Jane receives a check in the mail to pay her provider’s within 120 days. Additionally, Jane’s doctor has scheduled a follow-up appointment the next month which Jane will submit through the member portal as an add-on bill once completed.
Common CHM Language
Due to CHM not being an insurance company, they use different terminology. Below is common language used by CHM: Sharing. Occurs when CHM reimburses the employee for an eligible incidents (think “covers”). Total Cost. Total cost of the bill before private-pay discounts are applied. Private-pay discounts (or cash discount). Discount given by a healthcare provider. Need. An individual medical bill. A need is categorized under a particular incident which falls under a certain illness/diagnosis. Incident.Has a definite timeline, can be made up of several needs (bills) and includes medical treatment or testing that last until one of the following events occurs:
1. Certain medical condition is cured according to official medical records; 2. Treatment is at a routine maintenance level; or 3. Patient experiences 90 days without any kind of testing or treatment for that particular condition.
The medical need(s) incurred from the first appointment/test to the last treatment before the doctor releases you to a regular, routine maintenance regimen are considered a single incident. If 90 days passes and you receive no further testing or treatment, any future bills incurred will be considered a separate incident. If that separate incident does not meet the over $500 criteria for CHM, then it will be considered an HRA expense. Itemized Bill. Required for any need to be submitted to CHM. An itemized bill6 contains:
1. Patient’s name;
2. Date of service;
3. Place of service;
4. Total cost of service;
5. Procedural code (CPT)
6. Private-pay discount/cash discount (or adjustment), if received.
Add-on Itemized Bill. Any additional services related to the same incident (occurring within 90 days of last activity) that are incurred after original submission of needs, can be submitted through the CHM Member Portal as an add-on (instructions). Submitting Needs. Submission of needs for an incident through CHM’s member portal for sharing.
To see how Jane would complete the required forms for these items, go here.
6 Sample itemized bills.
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Helpful Tip:
Some providers are unable to
provide you with an itemized bill
until they process it (usually 2
weeks) and most of the time
you have to call to remind them.
IMPORTANT:
Your needs must be submitted within six months of the date of service. The sooner CHM
receives the bills, the sooner they can get them into the system for sharing. If an employee
does not submit their bills within six months of the date of the need, the employee will be
responsible for paying the bills out-of-pocket. This will not be a HRA eligible expense.
Procedure for CHM Eligible Expense
In the event that you have an over $500 total cost, CHM eligible medical expense, you should seek appropriate care from the health care provider of your choice and follow the procedure below: If possible, prior to going to your provider’s office:
1. Communicate you are a private pay patient.You would like the private-pay discount (or cash discount). A 25-60% discount is normal.
2. After services (or some providers would like payment
before services), obtain an itemized bill of services.
3. If the provider ask for payment:
○ Ask if you can be placed on a payment plan. Do
not use your Benefits Card to pay for this expense.
○ If they do not offer a payment plan:
i. Contact CHM, if it is a large amount ($2,000+) and you have to pay it upfront.
CHM will direct you on next steps.
ii. Pay in full on personal card ONLY if you receive a discount.
iii. If you have to pay up front and floating the amount represents a financial
hardship, follow these advance instructions.
4. Complete the CHM required forms (examples of these forms).
○ Letter of Explanation: a short explanation of your medical incident
○ Needs Processing Form: provides CHM with necessary information to process your
incident.
○ Medical Release Information (HIPAA-compliant) Form (only one submission is required
per covered individual, per year): allows medical providers to share information with us
in order to share your incident.
○ Needs Processing Worksheet: a necessary worksheet for CHM to see the total amount
paid and the discounts received.
○ Itemized Bill(s): bill received from your healthcare provider with the necessary
information for CHM to process your incident.
5. Upload required forms and itemized bill to the CHM Member Portal (instructions).
6. CHM will review the needs to make sure they are eligible. The timeline for sharing is 90-120
days from date of submission.
7. CHM will send you a check to reimburse you. 8. Pay your healthcare provider(s).If you have have partially or fully paid for your bills, you will
reimburse yourself the amount you paid. The remainder should then be paid to the provider. 9. Make sure that all itemized bills for the incident have been submitted. If you receive an
additional bill after your initial CHM Member Portal submission, you will need to submit bill in the member portal as an add-on bill (instructions).
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Emergencies
If there is an emergency, our first concern is you and/or your family’s health. Once you are able, let the
provider know you are a private-pay patient and ask for the private-pay discount. If the provider states
that they will not put you on a payment plan and you have to pay before emergency services are done
to get the private-pay discount, there are a couple of options:
1. Contact CHM’s Member Advocate department and explain the situation and see if they can get
a day-of-service payment processed for you.
2. Place the charge on your personal credit card. If the amount charged is a financial hardship for
your family, follow the process to submit an advance.
3. If the two options above are not available, contact HR and they will place it on a church credit
card for you to reimburse once you get a check from CHM.
These steps are to be followed in a true emergency situation where they are asking for upfront payment
prior to emergency services being done. After you have had time to recover and process, make sure to
follow the instructions to submit the needs through the CHM Member Portal.
Advance Request
If the payment needing to be made is a financial hardship on you and your family, there is an advance
available while you are waiting for CHM’s sharing. For instructions, please contact Denise Moss. The
following items must be met, before an advance can be made:
1. Total, unreimbursed out-of-pocket medical expenses for current plan year, represent a financial
hardship for your family. Medical expenses paid on a Benefits Card are not eligible for an
advance.
2. Claim has already been submitted to CHM.
3. Employee asked for a private-pay discount. If the provider does not offer a private-pay discount,
this is okay, but we require you to ask for one (this is usually not the case).
4. Employee asked to be placed on a payment plan and one was not available through the
provider.
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CHM Frequently Asked Questions
Q: What if a CHM eligible incident total cost is over $500, but after private-pay discounts, is
under $500, is it still eligible to be reimbursed by CHM?
Yes, this incident is still eligible to be reimbursed by CHM. For example, John has a doctor appointment
and an x-ray. The total cost is $650, but after private-pay discounts the total went down to $400. John
would still submit this to CHM for sharing.
Q: Will I receive any communication from CHM throughout the year?
Yes, you will receive emails from CHM that contain their monthly newsletter and monthly giving form. In
addition, you will receive a quarterly brother’s keeper letter via email. There is NO ACTION required on
your part.
Q: When setting up my CHM Member Portal access online, it asked for an access code. Where is
the access code found?
Your access code for you and your covered members will be on your monthly gift form. You should only
have to use the access code to register for the member portal once. After initial registration, you will just
use your email address and chosen password. If you are unsuccessful in finding your access code, you
can also contact CHM at 1-800-791-6225 to obtain it. Due to privacy, HR will be unable to obtain your
access code for you.
Q: My healthcare provider can only give me an estimate or a future bill prior to services being
rendered. Does CHM accept a future bill or an estimate?
CHM will not accept a future bill or an estimate. They will only accept itemized bills. CHM suggests to
still submit the incident with the estimate or future bill. Although, they will be unable to pay off of the
estimate or future bill, it can help expedite the sharing process once the actual bill has been received by
CHM.
Q: How do I know if my over $500 incident is CHM eligible?
CHM has Guidelines that list the incidents that are eligible and ineligible for sharing. The incidents that
are eligible for sharing can be found on page 20 (Guideline N) and the ineligible list of incidents can be
found starting on page 45 (Appendix). If you are still unable to find an answer, contact CHM at 1-800-
791-6225.
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CHM Member Portal Instructions
The CHM Member Portal is the secure, online platform to submit your needs to CHM. In order to
properly submit needs to CHM, you will need to submit the necessary forms, listed below, and the
appropriate itemized bills.
CHM Required Forms
Letter of Explanation. a short explanation of your medical incident
Needs Processing Form. provides CHM with necessary information to process your incident.
Medical Release Information (HIPAA-compliant) Form. allows medical providers to share
information with us in order to share your incident.Only one submission is required per covered
individual, per year.
Needs Processing Worksheet. a worksheet for CHM to see the total amount paid and the discounts
received.
Itemized Bill(s): bill received from your healthcare provider with the necessary information for CHM to
process your incident. An itemized bill contains:
1. Patient’s name;
2. Date of service;
3. Place of service;
4. Procedural code (CPT)
5. Private-pay discount (or adjustment), if received.
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CHM Member # is found on your
healthcare card
Access code is found on your monthly gift form (sent via email)
Initial Member Portal Setup
1. Go to https://www.chministries.org/members.aspx.
2. Click on “Register For Online Access” under Create Your Online Account.
3. Complete the fields with the appropriate information below and click on “Register Now”. You will only
need to create your online account once. If you have an incident you need to submit follow Submitting
Needs in the Member Portal.
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Submitting Needs in the Member Portal
1. Go to https://www.chministries.org/members.aspx.
2. Enter the email address and password you previously registered with and click “Sign In.”
3. Once signed in, you will need to click on “Submit Medical Need Online” under Medical Needs on
the left hand side. In addition to submitting a need, you are also able to view the status of
documents submitted online, sample medical bill log, download needs processing forms,
download CHM Guidelines, and change your password/email. The items marked through, do
not apply to you.
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4. Download the appropriate forms and completely fill each one out (sample forms). You do not
need to fill out the Prayer Page form.
5. Upload the completed forms in the appropriate fields. If you have multiple itemized bills, you will
need to add these by clicking “add another itemized bill”, under the first itemized bill file upload.
Helpful Tip: Double check that you have uploaded all of the appropriate files prior to selecting “Upload All Files.” The member portal does not have required fields.
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6. Once you have successfully uploaded all of the necessary files, you will need to select “Upload
All Files.” Note: If this is a maternity need, make sure to check next to “This is a Maternity
Need.”
7. A confirmation message will appear after submission at the bottom of your screen, under
Upload All Files. It is a very subtle, so make sure to look closely.
8. You can view a list of submitted items by clicking “View Documents Submitted Online”on the
main menu on the left hand side.
Submitting Add-On Bills
Any additional services related to the same incident (occurring within 90 days of last activity) that are incurred after original submission of needs, can be submitted through the CHM Member Portal as an add-on bill. To submit an add-on bill, follow steps 1-3 then upload the add-on itemized bill under Itemized Bill and then check next to “This is a add-on bill”.
Helpful Tip: Take a screenshot of the confirmation message and save it.
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Maternity Instructions
CHM shares qualifying medical bills for prenatal, delivery (including cesarean and multiple births),
home births, midwives7, postnatal up to six weeks and if any complications arise for mother and baby.
Below you will find what CHM shares at each stage of pregnancy.
Though maternity costs are eligible as described below, there will be times, depending on your
provider, that you may need to pay up-front for some services and wait until CHM shares them (90-120
days). If these expenses represent a financial hardship for you and your family, follow the advance
instructions.
Maternity Medical Bills CHM Shares
1. Prenatal:
a. Routine office visits
b. Blood work
c. Up to 3 ultrasounds (unless there is a complication that requires more)
d. Genetic testing, only if required to determine treatment for a current medical condition
(medical records must be submitted for approval)
e. Prescriptions related to pregnancy, except supplements purchased without a
prescription
2. Delivery:
a. OB/GYN labor and delivery charges OR certified midwife charges
b. Hospital labor and delivery charges OR birth center charges8
c. Hospital room and board
d. Anesthesiologist (if applicable)
e. Charges for complications if they arise for mother and baby
f. Circumcision (if applicable)
g. Baby immunizations while still admitted at the hospital
3. Postnatal
a. Mother 6-week office visit and corresponding pap test
b. Lactation consultations (if proof that it is medically necessary)
c. Baby well check-ups up to 6 weeks
Maternity Medical Bills Covered by HRA
1. Prenatal:
a. Genetic testing, if desired, and not required to determine treatment for a current medical
condition (CHM shares this).
b. Immunizations (dtap, flu shot, etc.)
2. Postnatal:
a. Baby immunizations, after hospital stay
7 CHM shares for either a midwife or an OB/GYN, not both. They cannot share expenses from more than one
midwife. 8 If complications arise and there is a need to take mom/baby to the hospital, this is eligible for sharing.
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Cost Saving Tip: Blood work can often be performed
at a fraction of the cost at a lab outside of your doctor’s office.
Helpful Tip:
You will also need to discuss payment options with the pediatrician who will perform the baby’s check-up at the hospital as these services are usually billed separately.
b. Breast pumps: we recommend purchasing the breast pump with your personal card and
then submitting it to EBC for a manual reimbursement (instructions). A prescription is
required from your OB/GYN which will need to be uploaded with your receipt (you can
purchase through Target, Amazon, etc.). We suggest these two options: Medela Pump
In Style Advanced Breast Pump On-The-Go Tote or Medela Pump in Style Advanced
Breast Pump with Backpack.
Maternity Expenses not Covered by Plan
1. Doula services
2. Birthing tubs or related items if delivering with midwife
3. Childbirth education classes
OB/GYN Prepayment Agreement
You will need to obtain a prepayment agreement9, also known as a “stork package” or “global fee”, from
your OB/GYN as soon as possible. The prepayment agreement usually includes:
● OB/GYN office visits
● OB/GYN labor/delivery charges
● Sonograms/ultrasounds10
● Blood work
Once you have received your prepayment agreement, make sure to follow the instructions on
submitting the appropriate forms and needs through the CHM Member Portal.
Hospital Prepayment Agreement
If you plan to give birth at a hospital, you’ll need a hospital prepayment agreement (different from your
OB/GYN’s prepayment agreement). We recommend you request it three months prior to delivery. The
hospital prepayment agreement can include:
● Labor and delivery charges
● Room and board, these are not always included in the hospital’s quoted price, so we suggest
asking if they aren’t included upfront
If the hospital requires payment upfront for a discounted rate
and/or they require a deposit before delivery, CHM will try to get
you the amount required prior to the baby being born (if submitted
to them in a timely manner). After delivery, you will need to submit
the final bill to CHM.
If the hospital does not require payment upfront, CHM will not
9 If your OB/GYN will not provide you with a prepayment agreement and will be billing you per visit, you will need
to submit an itemized bill that has each service listed to CHM. 10 Sonograms and blood work may not be included in your OB/GYN’s prepayment agreement, so you may have
to pay for each service as it is rendered. We suggest asking for a payment plan if possible. Do not use your Benefits Card for any eligible CHM maternity expense.
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share prior to delivery and the final bill will need to be submitted once received.
Once you have received your hospital prepayment agreement and have already submitted your
maternity need, make sure to follow the instructions for submitting an add-on bill.
Anesthesiology Charges
Anesthesiology charges are eligible for sharing, but CHM does not share these expenses prior to the
birth. If a deposit or payment is asked for upfront, you will need to pay with your personal card and then
reimburse yourself once CHM reimburses the need. You can upload the estimated bill into the CHM
Member Portal prior to the baby being born, then submit the final bill after the birth. This can help
significantly shorten the sharing time.
Birthing Center/Home Birth
If you are not giving birth at a hospital, you will just need one prepayment agreement with the provider
who will be delivering the baby. This prepayment agreement should include any services from prenatal
care, delivery of the baby, and postnatal care up to 6 weeks after the birth. Once you have received
your prepayment agreement, make sure to follow the instructions on submitting the appropriate forms
and needs through the CHM Member Portal.
CHM Maternity Contact
Lara Farnsworth, CHM’s maternity needs processor, can be reached at 1-800-791-6225, ext. 6599, or
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IMPORTANT:
Even though you have depleted your HRA, you should still be submitting all over $500
eligible expenses to CHM. The out-of-pocket is only for the HRA.
After Your HRA is Consumed
IF your HRA has been consumed, you will then move into the out-of-pocket phase of the plan for HRA
eligible expenses EXCEPT for preventive care items. If you have consumed your HRA and you have an
expense listed on the preventive care list, you submit that expense to HR for 100% reimbursement.
Out-of-Pocket Amounts
After your HRA has been consumed, you will need to meet the following out-of-pocket amounts11 for
eligible HRA expenses prior to getting reimbursed for any eligible HRA expense by the ASCC Health
Fund:
a. Employee Only: $900
b. Employee + Spouse: $1,550
c. Employee + Child(ren): $2,500
d. Employee + Family: $2,500
Keeping Track of Out-of-Pocket
You are responsible for keeping track of your out-of-pocket expenses. Once you have exceeded the
amount listed above for your tier, email Denise Moss for next steps.
Health Fund
IF out-of-pocket amounts are reached; coverage for eligible expenses under $500 are covered at 100% for the remainder of the plan year by ASCC through the Health Fund. For additional information, contact Denise Moss.
11 Preventive care list items are not subject to the out-of-pocket amounts and are 100% reimbursed by ASCC.
23
Preventive Care
Preventive Care is mandated by the Affordable Care Act (ACA) to be covered by employers at 100%
coverage. Depending on the preventive care service, it can be covered by CHM, HRA, or the Health
Fund. Any service listed is not subject to the out-of-pocket amounts. The official list may be found at:
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Preventive Care Benefits for Adults
1. Abdominal aortic aneurysm one-time screening for men of specified ages who have ever
smoked
2. Alcohol misuse screening and counseling
3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
4. Blood pressure screening
5. Cholesterol screening for adults of certain ages or at higher risk
6. Colorectal cancer screening for adults over 50
7. Depression screening
8. Diabetes (Type 2) screening for adults with high blood pressure
9. Diet counseling for adults at higher risk for chronic disease
10. Hepatitis B screening for people at high risk, including people from countries with 2% or more
Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one
parent born in a region with 8% or more Hepatitis B prevalence.
11. Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
12. HIV screening for everyone ages 15 to 65, and other ages at increased risk
13. Immunization vaccines for adults — doses, recommended ages, and recommended populations
vary:
a. Diphtheria
b. Hepatitis A
c. Hepatitis B
d. Herpes Zoster
e. Human Papillomavirus (HPV)
f. Influenza (flu shot)
g. Measles
h. Meningococcal
i. Mumps
j. Pertussis
k. Pneumococcal
l. Rubella
m. Tetanus
n. Varicella (Chickenpox)
14. Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy
smokers or have quit in the past 15 years
15. Obesity screening and counseling
16. Sexually transmitted infection (STI) prevention counseling for adults at higher risk
17. Syphilis screening for adults at higher risk
18. Tobacco Use screening for all adults and cessation interventions for tobacco users.
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Preventive Care Benefits for Women, Including Pregnant Women
1. Anemia screening on a routine basis
2. Breastfeeding comprehensive support and counseling from trained providers, and access to
breastfeeding supplies, for pregnant and nursing women
3. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization
procedures, and patient education and counseling, as prescribed by a health care provider for
women with reproductive capacity (not including abortifacient drugs). This does not apply to
health plans sponsored by certain exempt “religious employers.” Learn more about
contraceptive coverage.
4. Folic acid supplements for women who may become pregnant
5. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of
developing gestational diabetes
6. Gonorrhea screening for all women at higher risk
7. Hepatitis B screening for pregnant women at their first prenatal visit
8. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher
risk
9. Syphilis screening
10. Expanded tobacco intervention and counseling for pregnant tobacco users
11. Urinary tract or other infection screening
12. Breast cancer genetic test counseling (BRCA) for women at higher risk
13. Breast cancer mammography screenings every 1 to 2 years for women over 40
14. Breast cancer chemoprevention counseling for women at higher risk
15. Cervical cancer screening for sexually active women
16. Chlamydia infection screening for younger women and other women at higher risk
17. Domestic and interpersonal violence screening and counseling for all women
18. Gonorrhea screening for all women at higher risk
19. HIV screening and counseling for sexually active women
20. Human Papillomavirus (HPV) DNA test every 3 years for women with normal cytology results
who are 30 or older
21. Osteoporosis screening for women over age 60 depending on risk factors
22. Rh incompatibility screening follow-up testing for women at higher risk
23. Sexually transmitted infections counseling for sexually active women
24. Syphilis screening for women at increased risk
25. Tobacco use screening and interventions
26. Well-woman visits to get recommended services for women under 65
Preventive Care Benefits for Children
1. Alcohol and drug use assessments for adolescents
2. Autism screening for children at 18 and 24 months
3. Behavioral assessments for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14
years, 15 to 17 years
4. Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to
14 years, 15 to 17 years
25
5. Cervical dysplasia screening for sexually active females
6. Depression screening for adolescents
7. Developmental screening for children under age 3
8. Dyslipidemia screening for children at higher risk of lipid disorders ages: 1 to 4 years, 5 to 10
years, 11 to 14 years, 15 to 17 years
9. Fluoride chemoprevention supplements for children without fluoride in their water source
10. Gonorrhea preventive medication for the eyes of all newborns
11. Hearing screening for all newborns
12. Height, weight and body mass index (BMI) measurements for children ages: 0 to 11 months, 1
to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
13. Hematocrit or hemoglobin screening for all children
14. Hemoglobinopathies or sickle cell screening for newborns
15. Hepatitis B screening for adolescents at high risk, including adolescents from countries with
2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and
with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11 – 17 years.
16. HIV screening for adolescents at higher risk
17. Hypothyroidism screening for newborns
18. Immunization vaccines for children from birth to age 18 — doses, recommended ages, and
recommended populations vary:
○ Diphtheria, Tetanus, Pertussis (Whooping Cough)
○ Haemophilus influenza type b
○ Hepatitis A
○ Hepatitis B
○ Human Papillomavirus (PVU)
○ Inactivated Poliovirus
○ Influenza (flu shot)
○ Measles
○ Meningococcal
○ Pneumococcal
○ Rotavirus
○ Varicella (Chickenpox)
19. Iron supplements for children ages 6 to 12 months at risk for anemia
20. Lead screening for children at risk of exposure
21. Medical history for all children throughout development ages: 0 to 11 months, 1 to 4 years , 5 to
10 years , 11 to 14 years , 15 to 17 years
22. Obesity screening and counseling
23. Oral health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years
24. Phenylketonuria (PKU) screening for newborns
25. Sexually transmitted infection (STI) prevention counseling and screening for adolescents at
higher risk
26. Tuberculin testing for children at higher risk of tuberculosis ages: 0 to 11 months, 1 to 4 years, 5
to 10 years, 11 to 14 years, 15 to 17 years
27. Vision screening for all children
26
Contact Information
Christian Healthcare Ministries (CHM)
For CHM related questions in regards to eligible expenses, bill submission, status of submission, or any
other specific CHM question, contact CHM at 1-800-791-6225. For maternity specific questions, Lara
Farnsworth, CHM’s maternity needs processor, can be reached at 1-800-791-6225, ext. 6599, or
If you are contacting CHM, make sure that you provide the following information:
● First and last name
● Member number (if available)
● Group name: The Austin Stone Community Church
● Pre-existing conditions have been waived
Also, make sure that you write down the date you contacted CHM and ask for the name of the CHM
team member. This is helpful in regards to providing CHM feedback.
Employee Benefits Corporation (HRA)
Any questions related to the HRA and the Benefits Card, contact EBC at:
1-800-346-2126 | [email protected]
ASCC HR
For general questions in regards to our plan, the HRA, or the Health Fund, contact the HR department.
Michelle Tews, HR Manager
(512) 362-6468 | [email protected]
Denise Moss, HR Associate
512-535-8651 | [email protected]
27
Helpful Tip:
We suggest completing the medical history for you
and your dependents while signing up. Download their convenient app!
Additional Benefits
Teladoc provides you and your dependents 365/24/7 access to medical doctors via phone for non-
emergent medical issues. The medical consultation is provided at no additional cost to you and your
covered dependents and most customers experience a callback time of less than 10-15 minutes. If
medically appropriate, the doctor can send a prescription to your local pharmacy within 1-2 hours,
which is an HRA eligible expense. Types of conditions that Teladoc prescribes medical treatment for
include: cold & flu, bronchitis, allergies, pink eye, and upper respiratory infections.
Teladoc Account Set Up
1. Log on to https://member.teladoc.com/registrations.
2. Fill in all of the required fields: first and last name, email address, phone number, and date of
birth.
3. Under “Do you have a username or member ID?”, select No.
4. Under, “How did you find out about Teladoc?” Select “My employer or insurance provider offers
me access to Teladoc.”
5. Under, “Who is your employer or insurance provider?” Enter The Austin Stone Community
Church.
6. Choose continue and finish completing the registration on the next page.
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Dental
29
30
31
32
Vision - Optional
33
34
General Plan FAQS
Q: What if I don’t get a chance to tell the provider, prior to services, that I am a private pay
patient?
Once you are able, let the billing office know that you are a private pay patient and ask for a private pay
discount.
Q: What if I receive a bill in the mail, how do I know it is the correct private pay price?
Call the billing office prior to paying the bill and make sure that they know you are a private-pay patient
and would like to know the private pay discount. Often times, third parties think that if insurance isn’t
listed on the bill, that it was forgotten.
Q: What do I put on doctor’s form when it asked for the name of my insurance?
Private Pay Patient.
Q: What if I am filling out a form for my child to participant in an activity or an event and it asked
me what my insurance is?
Austin Stone Community Church Health and Wellness Plan.
Q: I have not received my welcome kit from Teladoc in the mail, am I still able to use Teladoc?
Yes, your account was active with Teladoc as of January 1 if you are a existing staff member or your
hire date if you were hired after January 1, 2018. Follow these instructions to setup your account.
Q: Is our HRA linked with CHM?
No. These are two separate components of our plan.
Common Ineligible Plan Expenses
● Acupuncture
● Out-of-Pocket Dental expenses after use of dental insurance
● Vision medical care, except for the exceptions provided
● Private duty nursing
● Marital and social counseling
● Nutritional supplements
● Over-the-counter medication
● Speech therapy related to developmental delay, education problems, training problems or
learning disorders.
● Elective, non-health related cosmetic surgery
● Non-medical supplies (postage, interest incurred, etc.
35
Appendix
EBC Quick Reference Guide
36
37
Submitting a Claim Online with EBC
38
Letter of Explanation Form Example
39
Needs Processing Form Example
40
Needs Processing Worksheet Example
41
Medical Release Information (HIPAA-compliant) Form Example
42
Doctor’s Office Itemized Bill Example
Health Imaging Itemized Bill Example
43
Lab Testing Itemized Bill Sample