89:; For - University of South Alabama

 
89:; For - University of South Alabama
89:;
                                      For            Employees

                                                      Coverage
                                                      you deserve.
                                                   Care
                                                   you demand.

Access to University of South Alabama providers.

                                                   USA-VIVA Guidebook 2019
89:; For - University of South Alabama
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&$'()-USA Health & Dental Plan representatives will be available at the Employee Benefits
Fair on Thursday, November 1, 2018 and Friday, November 2,2018, to answer your questions and
assist you with enrollment.
89:; For - University of South Alabama
May I join any of the three plans o?ered by the           Why are the benefits better and the premium lower
University: the Base Plan, the Standard Plan, or the      for the V"#$ 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.
89:; For - University of South Alabama
89:; For - University of South Alabama
89:; For - University of South Alabama
89:; For - University of South Alabama
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
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NOTES
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Coverage you deserve.                                   rage
                                                  Value you demand.
                                                                                                       Value
                                                                                                              Customer Service
                                                                                                      (205) 558-7474 or (800) 294-7780 or
                                                                                                        vivamemberhelp@uabmc.edu

                                                            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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