89:; For - University of South Alabama
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89:; For Employees Coverage you deserve. Care you demand. Access to University of South Alabama providers. USA-VIVA Guidebook 2019
V"#$ H&$'()-USA Health & Dental Plan is a narrow network plan that consists of USA Health medical providers and select providers The University of from the V?@B HCBDEF network. V?@B HCBDEF and USA Health South Alabama, together will ensure access to primary care and all medical specialties. in coordination The plan includes telehealth services that link members to Alabama- licensed physicians through phone or video chat for the treatment of with V:;< H=?@, minor medical concerns, improving the aLordability and convenience oBers employees of primary care. On the V?@B HCBDEF-USA Health & Dental Plan, the opportunity to out-of-network services are only available for urgently needed or emergency care or when approved by V?@B HCBDEF’s medical director. participate in a cost- eBective health and V?@B HCBDEF, located in Birmingham, AL, is part of the University of dental plan, V:;< Alabama at Birmingham (UAB) Health System. V?@B HCBDEF is one of the largest health insurers in the state, with over 100,000 Medicare H=?@-USA Health and commercial lives. V?@B HCBDEF administers the V?@B HCBDEF- & Dental Plan! USA Health & Dental Plan for USA employees and their families. The monthly employee cost for the V"#$ H&$'()-USA Health & Dental Plan is the lowest of the plans o?ered by USA Health: Single - $90.00/month* Family - $300.00/month* *Includes the non-tobacco wellness incentive of $50.00/month. Contact the USA Human Resources Department for more information. V"#$ H&$ $'()-USA Hea Health & Dental Pllan saves employees $456 for single coverage and $1,416 for family coverage annually, compared to the USA Health & Dental Plan’s Standard Plan. The plan does not have a medical deductible and has $0 copayments for hospital and physician services, as well as many other services. The pharmacy beneﬁt, administered by Express Scripts, Inc., and the dental beneﬁt, administered by Southland National, are identical to the pharmacy and dental beneﬁts provided by the USA Health & Dental Plan’s Standard Plan. Open Enrollment for the V"#$ H&$''()-USA A He Health alth & D Dental Pla lan begins Thursd day, November 1, 2018 and ends Friday, November 30,2018. Enrollment in the V"#$ H&$''()-USA Health & Dental Plan is voluntary ry for all beneﬁts-eligible employees. V"#$ H&$'()-USA Health & Dental Plan representatives will be available at the Employee Beneﬁts Fair on Thursday, November 1, 2018 and Friday, November 2,2018, to answer your questions and assist you with enrollment.
May I join any of the three plans o?ered by the Why are the beneﬁts better and the premium lower University: the Base Plan, the Standard Plan, or the for the V"#$ H&$'()-USA Health & Dental Plan? V"#$ H&$'()-USA Health & Dental Plan? The network providers in the V?@B HCBDEF-USA No. If you are a new employee, you may select Health & Dental Plan network have agreed to accept a between the Standard Plan and the V?@B HCBDEF- lower fee for services, resulting in lower costs for you. USA Health & Dental Plan. Only employees hired The plan’s network providers work to achieve better before January 1, 2013, are eligible for the Base Plan. medical outcomes through integrated care, which also reduces costs. The beneﬁts for medical services Does the V"# #$ H&$'()-USA Health & Dental Plan oLered by the V?@B HCBDEF-USA Health & Dental o?er denta al beneﬁts? Plan are richer than those oLered by the Standard Yes, the V?@B HCBDEF-USA Health & Dental Plan Plan, but the pharmacy and dental beneﬁts for the two oLers the same dental beneﬁts as the Base Plan and plans are the same. the Standard Plan. If I join n the V"#$ H&$'()-USA Health & Denttal Who se elects the network providers for the Plan, can I decide to change plans later on? V"#$ H&$'()-USA Health & Dental Plan? You may only change to the Standard Plan and only V?@B HCBDEF has the sole responsibility for selecting during the annual open enrollment month (generally medical providers to be included as network in November) for coverage starting January 1st of the providers in the V?@B HCBDEF-USA Health & Dental following year. You may not change plans outside of Plan. V?@B HCBDEF monitors these providers for the annual open enrollment month unless you have a access, quality of care, and medical outcomes to change in residence that involves a move outside the ensure the highest level of medical providers are state of Alabama. If you are eligible to change from included in the network. V?@B HCBDEF has the sole the V?@B HCBDEF-USA Health & Dental Plan, you authority to add and remove providers from the plan’s may only join the Standard Plan; you may not change network. back to the Base Plan. Howw do I join the V"#$ H&$'()-U USA Health & Willl my doctor be covered under the V"#$ Denntal Plan? H&$$'()-USA Heallth & Dental Pla an? You must complete an enrollment form and ﬁle it The V?@B HCBDEF-USA Health & Dental Plan’s with the University’s human resources department. network is limited to USA physicians and select When you ﬁle an enrollment form, you will attest to specialists amliated with other hospitals within your understanding of the following: the V?@B HCBDEF network. Consult the Provider 1. The V?@B HCBDEF-USA Health & Dental Plan Directory for the V?@B HCBDEF-USA Health & Dental is a limited network plan that does not provide Plan to determine if your doctor is included in the beneﬁts for out-of-network medical providers network. You can verify your physician’s status except for urgently needed and emergency by calling V?@B HCBDEF at 1-800-294-7780 or by medical care and services approved by V?@B searching the Provider Directory online at www. HCBDEF’s medical director in advance. viva-usa.com. Remember: medical care you receive 2. It is your responsibility to ensure that your from providers who are not included in the V?@B medical care and the medical care of your spouse HCBDEF-USA Health & Dental Plan network will not and/or dependents on the plan are provided by a be covered by the plan unless it is urgently needed network provider. or emergency medical care or approved by V?@B 3. You may not change from the V?@B HCBDEF- HCBDEF’s medical director in advance. USA Health & Dental Plan except during open Are referralls by network providers to medical enrollment for coverage eLective January 1st of providers outstside the network covered d by the V"#$ the following year, unless you have a change of H&$'()-USA Health & Dental Plan? residence that involves a move outside the state No. Care received from out-of-network medical of Alabama (see the rule for Change-in-Status providers will generally not be covered by the plan, Events in your Member Handbook). even when referred by a network provider. Out-of- network care will only be covered if it is urgently needed or emergency medical care or if it is approved by V?@B HCBDEF’s medical director in advance.
Southland Member Guide Using Your Southland Dental Plan 3OHDVH5HDG7KLV,PSRUWDQW,QIRUPDWLRQ%HIRUH8VLQJ
ACCESS ENROLLMENT/STATUS CHANGE FORM ܆New Enrollment ܆Re-Enrollment ܆Change Information ܆Request Termination Show Reason for Change: ܆Address Change ܆COBRA ܆Single to Family Primary Language: ܆Marriage ܆Employment Terminated ܆Open Enrollment ܆English ܆Birth/Adoption ܆Not An Eligible Employee ܆Name Change ܆Spanish ܆Moved Out-of-Area ܆Not An Eligible Dependent ܆Family to Single ܆Other Employee Name: ;>ĂƐƚ͕&ŝƌƐƚ͕DŝĚĚůĞ/ŶŝƚŝĂůͿ Hire Date: Home Address: Apt. Number: City: State: Zip Code: Home Telephone Number: Work Telephone Number: Employer: Division Location: ( ) ( ) DEPENDENTS TO BE COVERED Individuals listed below may include those eligible according to the Certificate of Coverage. Additional information may be required if spouse and/or children do not have the same last name as the employee (i.e., birth or marriage certificate) Name of Person to be Covered Social Security Number Sex Date of Birth Last First MI Employee ܆M ܆F Spouse ܆M 1 ܆F Resides with Employee ܆Yes ܆No Child ܆M 1 ܆F Resides with Employee ܆Yes ܆No Child ܆M 1 ܆F Resides with Employee ܆Yes ܆No Child ܆M 1 ܆F Resides with Employee ܆Yes ܆No Child ܆M 1 ܆F Resides with Employee ܆Yes ܆No 1 Coverage will not be offered to dependents living outside the service area. The service area is defined as the state of Alabama. If you are subject to a court decree to provide health coverage for any dependent(s) listed above, please provide a copy of the decree. Are you presently covered on a health insurance plan? ܆Yes ܆No If yes, how long has this coverage been continuous? ____________________ If yes, what type of coverage: ܆Spouse’s Coverage ܆COBRA ܆Present Employer’s Coverage ܆Medicare/Medicaid ܆Other ____________ Name of Present Insurance Company: ________________________________ Name of Policy Holder: _____________________________________ Policy # or Medicare #: _____________________________________ Address of Insurance Company: _____________________________________ After coverage becomes effective with VIVA HEALTH, Inc., are you or any family members to be covered by another medical insurance or Medicare? ܆Yes ܆No EMPLOYER VERIFICATION Employer Signature: Group Number: Employment Date: Effective Date: ____________________________________________________ VIVA HEALTH complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-294-7780 (TTY: 711). ὀពዴᯝᝍ⏝⦾㧓୰ᩥ㸪ᝍྍ௨ච㈝⋓ᚓㄒゝຓ᭹ົㄳ⮴㟁 1-800-294-7780㸦TTY㸸711 VUSA ENROL2018 10/2017
MEM MBER BERSHIP CONDITIONS DITIO I am aware of and accept the following V?@B HCBDEF, Inc. membership conditions: 1. I understand that the V?@B HCBDEF-USA Health & Dental Plan is a limited network plan and the service area is deﬁned as the state of Alabama. 2. I authorize the release and use of all my medical records or information necessary to process claims or in any way determine beneﬁts due. Medical information can also be used to execute the obligations imposed on V?@B HCBDEF, Inc. by state or federal status, as well as for the Quality Assurance or Peer Review programs conducted by V?@B HCBDEF, Inc. or its designated agents. 3. I authorize my employer to deduct premium contributions, if any, from my wages or salary with the understanding that my employer acts as my agent in all dealings with the V?@B HCBDEF-USA Health & Dental Plan where not prohibited by statute or regulation. 4. I have read and understand the membership information available in the enrollment materials including the description of exclusions and limitations. I will abide by the Group Health Policy and Certiﬁcate of Coverage applicable to the plan in which I enrolled, and will be responsible for ensuring my dependents follow instructions and abide by conditions listed therein. 5. I understand any service not provided by a participating physician or authorized by V?@B HCBDEF, Inc. will not be covered and will be my responsibility. 6. I understand that the V?@B HCBDEF-USA Health & Dental Plan is a limited network plan that does not provide beneﬁts for out-of-network medical providers except in the case of urgently-needed and emergency medical care, and then only after proper notiﬁcation, or medical care approved by V?@B HCBDEF’s medical director in advance. I understand that it is my responsibility to ensure that medical care, is provided by a Network Provider. I understand that I may not change from the V?@B HCBDEF-USA Health & Dental Plan except during open enrollment for coverage eLective January 1 of the following year. 7. I understand that if I am currently a USA Health & Dental Base Plan participant and I voluntarily elect to participate in the V?@B HCBDEF-USA Health & Dental Plan but later elect to change from the V?@B HCBDEF- USA Health & Dental Plan, I may only enroll in the USA Health & Dental Standard Plan and may not re-enroll in the Base Plan. TOBACCO USE CERTIFICATION The VIVA HEALTH-USA Health & Dental Plan is committed to helping you achieve your best health. To this end, a Wellness Incentive is available to all employees. Contact the USA Human Resources Department for additional information. I understand that the Wellness Incentive is available to all employees. If I am unable to meet the standard under the Wellness Program, I understand that I may qualify for an opportunity to earn the same reward by diLerent means. Either I or my spouse have used tobacco products within the last six (6) months: ___ YES ___ NO Further, I attest that everything in my application is true. Printed name: _________________________________ Employee J#: __________________ Signature: _____________________________________ Date: _________________________
BENEFITS DEBIT CARD EMPLOYEE HANDOUT BENEFITS SPENDING MADE EASY ONE DEBIT CARD FOR ABILITY TO REQUEST NO FEES FOR LOST ALL OF YOUR BENEFITS ADDITIONAL CARDS FOR OR STOLEN CARDS A SPOUSE OR ELIGIBLE DEPENDENTS FOR FREE The Benefts Debit Card Submitting Documentation But, when in doubt, the IRS has identiﬁed The Discovery Beneﬁts debit card is the for Debit Card Transactions the criteria for what needs to be included fastest and most convenient way to pay Occasionally, documentation will be when submitting documentation for for eligible expenses. The debit card needed to verify the eligibility of an eligible expenses: makes it easy to access funds in your expense paid for on your debit card. • Name of the provider/merchant pre-tax beneﬁts accounts, reducing your Even places like doctors’ and dentists’ • Date(s) of service out-of-pocket costs. At many merchants, oEces may require you to submit • Type(s) of service it also simpliﬁes the way expenses are documentation because some expenses • Amount (af@er insurance, if veriﬁed for eligibility. available at these facilities may not be applicable) IRS-eligible (e.g. cosmetic procedures, • Name of person who received the How It Works teeth whitening). services (if the account covers Swipe your beneﬁts debit card to instantly dependents) pay for eligible expenses with funds from When Documentation Isn’t Needed your beneﬁts accounts. Where you swipe • When used at an IIAS merchant How to Submit the card will determine whether any • When used for recurring expenses You can submit documentation in seconds steps are needed af@er that. In addition that match the provider and dollar using the Discovery Beneﬁts mobile app. to using your beneﬁts debit card to pay amount for previously substantiated Our app is the quickest and easiest way to for services at your healthcare provider’s claims submit documentation because it lets you oEce, you can also use it at the following • When used for co-payments tied use your phone’s camera to take pictures types of merchants: to the account holder’s health plan of your documents and upload them on (Note: These amounts need to be the spot. IIAS communicated to Discovery Beneﬁts Many merchants provide IRS-required by your employer) information for documentation right at • When used to access HSA funds DOWNLOAD THE APP the point of sale through an Inventory FOR FREE ON APPLE AND Information Approval System (IIAS). If none of the above criteria apply, ANDROID DEVICES An IIAS merchant auto-substantiates you’ll be notiﬁed via email or mail that the claim, so you won’t need to provide documentation is needed. additional documentation on qualifying expenses. What to Submit You can also submit documentation When submitting documentation for a through your online consumer portal or 90% Merchants debit card transaction, an Explanation Our debit card also works at pharmacies via fax or mail. No matter how you choose of Beneﬁts (EOB) from your insurance to submit documentation, we’ll process or drug stores that meet the IRS’ 90 company will typically be your best bet, percent rule. At least 90 percent of the your claim in two business days. as it contains all the information you gross sales at these merchants come from need to substantiate a claim. eligible medical expenses. For a full list of IIAS and 90 percent rule merchants, visit Watch our Easy Substantiation video at www.DiscoveryBeneﬁts.com/easysubstantiation to learn more about submitting documentation for debit card transactions. www.DiscoveryBeneﬁts.com. www.DiscoveryBeneﬁts.com 08/21/17
www.DiscoveryBenefits.com · 866-451-3399 www.DiscoveryBenefts.com Flexible Spending Account (FSA) Data Collection Worksheet Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection purposes. Worksheets returned to Discovery Benefts cannot be processed. *=Required Fields Step 1: Participant Information *Employer Name (Do not abbreviate) Employee ID Number - - *Participant Name (First, MI, Last) *Social Security Number *Participant Mailing Address *City *State *Zip - - Email Address Day Telephone *Date of Birth (mm/dd/yyyy) *Hire Date (mm/dd/yyyy) *Gender (M/F) *Marital Status (Married/Single) Step 2: Employee Premiums If you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will automatically be enrolled in this portion of your Section 125 Plan. However, if you wish, you may opt out of the Employee Premium Conversion part of the Plan by contacting your HR Department and ﬁlling out the waiver form. Note: Insurance premiums are not eligible for reimbursement with your Medical or Limited Medical Spending Account. Step 3: Enrollment and Election Information *Plan Type (If enrolled in an HSA, you are not eligible to enroll in the Medical FSA. Medical FSA Dependent Care Account Limited FSA However, you are eligible for both the Limited Medical FSA and Dependent Care Limit set by employer Limit set by employer Limit set by employer if FSA if oXered through your employer.) up to IRS maximum this plan type is oXered *Annual Election (if employer funded, note “ER” next to amount): $ $ $ *Number of Pay Periods (if enrolling mid-year, please enter the number of remaining pay ÷ ÷ ÷ periods within the plan year): *Per Pay Period Amount (to be deducted each pay period): = = = *Date of First Payroll (mm/dd/yyyy): *Participant EKective Date (mm/dd/yyyy): *Pay Frequency (please check one): Monthly Semi- Bi-Weekly Bi-Weekly Weekly Other Monthly 24 26 Step 4: Authorization I authorize my employer to reduce my pay on a per-pay-period basis as indicated above. I understand my reduction is for one ﬂex plan year and that I cannot change or revoke my election unless I experience a qualifying event in accordance with Internal Revenue Code Section 125 and submit my request within a reasonable amount of time as deemed by the IRS and my employer. I am aware of the plan’s forfeiture provision and that my Social Security and federal unemployment beneﬁts may be reduced because of my reduced salary for tax purposes. Further, I authorize the release of any information necessary to substantiate claims submitted against my Flexible Spending Account. *Participant Signature *Date Step 5: Refusal (Note: Only complete this step if you are NOT electing to enroll in a Flexible Spending Account) Participant Signature Date Revised 6/27/16
Getting started with Teladoc Cómo aĤïiarse a Teladoc Teladoc® gives you 24/7/365 access to U.S. board- Teladoc® le da acceso 24 horas, 7 días a la semana todos los días del año a una lista de médicos medical care. Set up your account today so when you need care now, a Teladoc doctor is just a call or cuando necesite la atención inmediata, un médico de click away. Teladoc esté a sólo una llamada de distancia. 1. REGISTER 1. REGÍSTRESE 3 easy ways: download the mobile app, visit the Teladoc website or call the number below. representante lo ayudará a registrar su cuenta. 2. PROVIDE MEDICAL HISTORY 2. PROPORCIONE SUS ANTECEDENTES MÉDICOS Your medical history provides Teladoc doctors Sus antecedentes médicos proporcionan a los with the information they need to make an médicos de Teladoc la información que necesitan accurate diagnosis. para realizar un diagnóstico seguro. 3. REQUEST A VISIT 3. SOLICITE UNA CONSULTA That's it! A Teladoc doctor is now just a call or ¡Eso es! Un médico de Teladoc está a sólo un click away. llamado de distancia. Talk to a doctor anytime for free! ¡Hable con un médico en cualquier momento por gratis! Teladoc.com 1-800-Teladoc ©2002-2017 Teladoc, Inc. All rights reserved. Complete disclaimer at Teladoc.com. Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. ©2002-2017 Teladoc, Inc. Todos los derechos reservados. Complete el descargo de responsabilidad en Teladoc.com. Apple y el logo Apple son marcas registradas de Apple Inc. registrado en los Estados Unidos y otros países. App Store es un servicio de la marca Apple Inc.
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Coverage you deserve. rage Value you demand. Value Customer Service (205) 558-7474 or (800) 294-7780 or email@example.com A Product of VIVA HEALTH A Member of the Health System www.vivahealth.com 417 20th Street North, Suite 1100, Birmingham, Alabama 35203 VIVA HEALTH complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-294-7780 (TTY: 711). 1-800-294-7780 (TTY: 711).
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