Revisions to the USA Health & Dental Plan Handbook
Effective 01/01/2010

The monthly employee premium will increase by $9/single coverage and $22/family coverage. The following
provides the cost-sharing amounts effective January 1, 2010:
January 1, 2010







Single
Family
Employee
$ 76.00
$ 252.00
University
$ 326.00
$ 584.00
Total Cost
$ 402.00
$ 836.00
Reinstate the $25 annual deductible to the Dental Plan. The deductible will NOT apply to diagnostic and
preventive services. The deductible WILL apply to restorative, supplemental, endodontic, prosthetic, and
periodontic services. The annual $25 deductible is limited to three deductibles per family.
Increase the major medical deductible from $250 to $400.
Increase the non-USA physician (Blue Cross Blue Shield providers) visit copay from $25 to $30. In each case,
where there is a $25 copay for physician services, it will increase to $30. There will be NO change to the USA
Health System providers copay of $10.00.
Increase the non-USA inpatient hospital (Blue Cross Blue Shield providers) cost from a $500 deductible and $50
copay for days 2 through 5, to a $750 deductible and $100 copay for days 2 through 5.
Increase the non-USA outpatient hospital (Blue Cross Blue Shield providers) copay from $150 to $250. There
will be NO change to the USA Health System providers copay.
Diagnostic lab tests and pathology - Plan pays 100%; no copay.
Change the mental health treatment benefit to pay at 100% for an outpatient psychiatrist, psychologist, licensed
professional counselor, and licensed social worker after the $25 per visit copay with a limit of 60 visits per year
(this change eliminates the $250 annual deductible).

Increase the home health care benefit annual maximum benefit to $40,000 (from $30,000).

Increase the prescription drug copay from the current schedule of $10/$25/$35 to $10/$30/$50.


Add a specialty drug copay of $100. Specialty drugs are high-cost drugs that may be used to treat certain
complex and rare medical conditions and are often self-injected or self-administered. To find out if your
prescription is considered a specialty drug, go to www.bcbsal.com and select the PHARMACY link at the top
of the page. Once you are on the pharmacy page, select the Prescription Drug Guide and Drug Lists. You
may then search by drug name or select the Specialty Drug List.
Generic Proton Pump Inhibitor (PPI) Program Saves You Money. Proton Pump Inhibitors such as Nexium
are prescribed to treat heartburn, gastroesophageal reflex disease (GERD) and ulcers. You may take advantage of
the opportunity to be copay-free for six months by:
 switching from your brand name PPI to the generic PPI Omeprazole,
 receiving Omeprazole on any new, first-time PPI prescription,
 taking Omeprazole as your currect PPI prescription
New employees and their eligible dependents are required to serve a
270-day pre-existing conditions exclusion waiting period.
USA HEALTH & DENTAL PLAN
Please read this Member Handbook carefully and retain for future reference. It is important that you understand
the health and dental plan offered by the University of South Alabama so you will be able to obtain the maximum
benefit available. Please take time to review this Member Handbook and share it with your family.
ABOUT THIS USA HEALTH & DENTAL PLAN MEMBER HANDBOOK
This USA Health & Dental Plan Member Handbook has been prepared in an easy-to-read format to assist you
with understanding the Plan. It describes the benefits available under the Plan effective January 1, 2006, and
supersedes all previously published material. Certain words and terms have specific meaning and are capitalized
when used. These are explained in the Definitions section. Please read this section carefully.
The USA Health Plan Management Committee reserves the right to interpret the Plan, to amend or change the Plan,
terminate any or all benefits and to make final determinations with regard to all matters concerning the Plan.
Limitations and exclusions apply to some medical conditions and services. New Members are subject to a
waiting period during which no benefits are payable for a Pre-Existing Condition. Exclusions, limitations and
provisions are described in this Member Handbook.
SELF-FUNDING BENEFITS
The benefits provided to you and your Eligible Dependents by the USA Health & Dental Plan are self-funded.
The University of South Alabama and Eligible Employees pay the cost of all benefits. This funding method is
designed to reduce cost for you and for the University of South Alabama.
Employee eligibility is managed by the Human Resources Department and the University contracts with the
Claims Administrator, Blue Cross and Blue Shield of Alabama, to process claims and pay benefits in accordance
with the schedule of benefits.
Self-funding places responsibility upon all of us to spend money for benefits with the same care we would use in
spending our own money. There is a limit to the benefit dollars available. Prudent use of health care services will
preserve those benefit dollars. We must be aware of the cost of health care and act as wise health care consumers
when spending our money.
FOR ADDITIONAL INFORMATION
For questions concerning eligibility and enrollment, Change-In-Status Events, assistance in making Application
for coverage, or to obtain free-of-charge a directory of Blue Cross and Blue Shield Providers, contact:
HUMAN RESOURCES DEPARTMENTS
University of South Alabama Campus ...................460-6133
USA Medical Center...............................................471-7325
USA Children’s and Women’s Hospital.................415-1604
Website .................www.southalabama.edu/humanresources
For questions concerning claims payment, benefits, or to determine if a medical provider is a Blue Cross and Blue
Shield Provider, contact:
BLUE CROSS AND BLUE SHIELD OF ALABAMA
Regional Office Customer Service .........................343-4001
Website ...................................................... www.bcbsal.com
BlueCard PPO............................................... (800) 810-2583
USA HEALTH SYSTEM
Help Line ................................................................460-7862
Website ...................................... www.usahealthsystem.com
Group Number 13515
1
TABLE OF CONTENTS
SUMMARY OF BENEFITS
Description of Plans Offered..................................................................... 3
Benefits for Covered Services................................................................... 3
Benefit Exclusions..................................................................................... 3
Benefit Limitations.................................................................................... 4
General Plan Provisions ............................................................................ 4
BENEFIT EXCLUSIONS
Exclusions by Provision.......................................................................... 27
Health Plan Benefit Exclusion of Services............................................. 28
DENTAL PLAN BENEFITS
About the Dental Plan............................................................................. 30
Preferred Dentist Benefits....................................................................... 30
Non-Preferred Dentist Benefits .............................................................. 30
Preferred Dentist Directory..................................................................... 30
Freedom of Choice.................................................................................. 30
EMPLOYEE AND MEMBER RESPONSIBILITY
Responsibilities to the Plan ....................................................................... 5
Employee Responsibilities ........................................................................ 5
Member Responsibilities........................................................................... 5
SCHEDULE OF DENTAL PLAN BENEFITS
Dental Plan Calendar Year Maximum Benefit....................................... 31
Diagnostic and Preventive Services........................................................ 31
Dental Plan Calendar Year Deductible................................................... 31
Restorative, Supplemental and Endodontic Services ............................. 31
Prosthetic Services .................................................................................. 32
Periodontic Services................................................................................ 32
Prescription Drugs for Dental Services .................................................. 32
Dental Plan Benefit Limitations and Exclusions.................................... 33
ELIGIBILITY AND ENROLLMENT
Participation............................................................................................... 6
Eligible Employees ................................................................................... 6
Eligible Dependents .................................................................................. 6
Application for Coverage for New Employees......................................... 6
Important Notice for New Employees ...................................................... 6
Open Enrollment Period............................................................................ 7
Special Enrollment Period......................................................................... 7
Duplicate Coverage Excluded................................................................... 7
When Coverage Begins............................................................................. 7
When Coverage Terminates ...................................................................... 8
Continuation While on Approved Leave .................................................. 9
Surviving Dependent Health Benefit ........................................................ 9
Legal Protection for Continuation of Coverage........................................ 9
Active Employees Eligible for Medicare.................................................. 9
Termination and Reinstatement ..............................................................10
GENERAL PLAN PROVISIONS
Medical Necessity ................................................................................... 34
Allowed Amount..................................................................................... 34
Limitation of Liability............................................................................. 34
Right to Receive and Release Information ............................................. 35
Coordination of Benefits......................................................................... 35
Medicare Coordination of Benefits ........................................................ 36
Utilization Review .................................................................................. 36
Subrogation ............................................................................................. 36
Right of Reimbursement ......................................................................... 36
Right to Recovery ................................................................................... 37
Right to Recover Payments Made in Error............................................. 37
Receipt of Payment Satisfies Plan Obligation........................................ 37
How to File a Claim for Benefits............................................................ 37
Claim Inquiries........................................................................................ 38
Appeals to the Claims Administrator ..................................................... 38
Review Procedure When a Claim is Denied .......................................... 40
Delegation of Authority .......................................................................... 40
Relationship of Parties ............................................................................ 40
HEALTH PLAN BENEFITS
Freedom of Choice ..................................................................................11
About Blue Cross and Blue Shield Providers .........................................11
About USA Health System Providers.....................................................11
Benefit Levels..........................................................................................11
Provider Directories ................................................................................11
SCHEDULE OF HEALTH PLAN BENEFITS
Inpatient Hospital Benefits......................................................................12
Extended Care Facility Benefits..............................................................12
Hospice Benefits......................................................................................12
Outpatient Hospital Benefits ...................................................................13
Use of an Emergency Room ...................................................................13
Physician Benefits ...................................................................................14
Temporomandibular Joint Disorder Benefits..........................................14
Prescription Drug Card Benefits .............................................................15
Home Health Care Benefits ....................................................................15
Mental Health & Substance Abuse Benefits...........................................15
Major Medical Benefits...........................................................................16
BlueCard PPO Worldwide ......................................................................16
Preventive Care Services.........................................................................17
Baby Yourself..........................................................................................18
Individual Case Management..................................................................18
Care Management Program.....................................................................18
Personal Wellness Profile .......................................................................18
“CustomerAccess”...................................................................................18
FEDERAL LAWS AFFECTING YOUR BENEFITS
COBRA Continuation of Coverage ........................................................ 40
Family and Medical Leave ..................................................................... 45
Uniformed Services Leave...................................................................... 46
Qualified Medical Child Support Orders................................................ 47
Privacy Notice......................................................................................... 48
Creditable Drug Coverage Notice .......................................................... 49
SOUTHFLEX HEALTH AND DEPENDENT CARE
FLEXIBLE SPENDING ACCOUNT
Using Pre-Tax Dollars for Expenses ...................................................... 51
Participation in the Plan .......................................................................... 51
Use It or Lose It Policy ........................................................................... 51
Coordination with Health & Dental Plan ............................................... 51
Eligible Health Care Expenses ............................................................... 51
Health Care Expenses That are Not Eligible .......................................... 52
Eligible Dependent Care Expenses......................................................... 52
Dependent Care Expenses That are Not Eligible ................................... 53
Reimbursement Procedure...................................................................... 53
HEALTH PLAN COVERED SERVICES
Covered Services.....................................................................................19
Inpatient Hospital Covered Services.......................................................19
Outpatient Hospital Covered Services ....................................................19
Physician Covered Services ....................................................................19
Services Relating to Pregnancy and Delivery.........................................20
Other Covered Services...........................................................................20
SECTION 125 PREMIUM CONVERSION PLAN
Effective Date ......................................................................................... 54
Participation in the Plan .......................................................................... 54
Benefits Offered...................................................................................... 54
Enrollment Periods.................................................................................. 54
Termination of Employment................................................................... 54
Change of Election.................................................................................. 55
Review Procedure ................................................................................... 55
Administration ........................................................................................ 55
HEALTH PLAN BENEFIT LIMITATIONS
Pre-Existing Conditions Exclusion .........................................................24
Lifetime Maximum Benefit Limitation...................................................24
Calendar Year Maximum Benefit Limitation .........................................24
Mental Health & Substance Abuse Treatment Benefit Limitation.........25
Organ & Tissue Transplants Benefit Limitation.....................................25
Extended Care Facility Benefit Limitation .............................................25
Home Health Care Benefit Limitation ....................................................26
Hospice Care Benefit Limitation ............................................................26
Claims Filing Deadline............................................................................26
No Limitations on Length of Stay...........................................................26
DEFINITIONS .......................................................................................... 56
2
SUMMARY OF BENEFITS
The USA Health & Dental Plan has been designed to protect you and your family from significant financial loss
due to Illness or Injury. It is also designed to promote health and provide for medical and dental care at a
reasonable cost, while providing Members freedom of choice in selection of health care providers. The following
pages provide a brief description of the Plan, its provisions and limitations. Additional information may be found
in the appropriate sections of this Member Handbook. Please read this Member Handbook carefully.
DESCRIPTION OF PLANS OFFERED
Health Plan Blue Cross
and Blue Shield Providers
The USA Health Plan provides comprehensive benefits for services received within a
network of Blue Cross and Blue Shield Providers. Blue Cross and Blue Shield
Providers include Hospitals, Physicians, pharmacies, outpatient clinics and other
providers who have agreements with Blue Cross and Blue Shield of Alabama to
provide medical and surgical services. Outside Alabama, Blue Cross and Blue
Shield Providers are members of the BlueCard PPO Network.
Health Plan USA Health
System Providers
Within the USA Health Plan is a network of Hospitals, Physicians, outpatient clinics
and other providers affiliated with the University of South Alabama. Their
participation in the USA Health Plan allows Members to receive medical care at a
lower cost to both the Plan and the Member. The USA Health System Providers are
an important part of the USA Health Plan.
Dental Plan
The Dental Plan is administered by Blue Cross and Blue Shield of Alabama. You
must receive dental care from a Network Provider to receive the maximum benefit.
Services received Out-of-Network are subject to reduced benefits.
SouthFlex
Employees may enroll in the Health and Dependent Care Flexible Spending Account,
which allows you to pay for eligible non-Covered expenses with pre-tax dollars.
Section 125 Premium
Conversion Plan
Eligible Employees are enrolled in the Section 125 Premium Conversion Plan when
they elect to participate in the USA Health & Dental Plan. This Plan allows Eligible
Employees to pay the Employee Contribution with pre-tax dollars.
BENEFITS FOR COVERED SERVICES
Health Benefits
The USA Health Plan provides benefits for Illness or Injury when the Illness or
Injury occurs at the time the Member is covered under the Plan. In addition to
physical Illness, benefits are provided for Mental Health Treatment and Substance
Abuse Treatment, and for Pregnancy and childbirth for female Eligible Employees or
male Eligible Employees’ covered spouses.
Preventive Care
The USA Health Plan provides benefits for some preventive care services, as
described in this Member Handbook.
Covered Services
In all cases, benefits are provided only for Covered Services that are Medically
Necessary, subject to all Plan provisions, limitations and exclusions. Payment of
benefits is subject to any applicable Calendar Year Maximum Benefit and Lifetime
Maximum Benefit.
Lifetime Maximum and
Calendar Year Maximum
Benefits
The Lifetime Maximum Benefit is $1,000,000 per Member for all Covered Services.
Other Lifetime Maximum Benefit limitations apply to specific Covered Services.
Calendar Year Maximum Benefit limitations apply to specific Covered Services.
BENEFIT EXCLUSIONS
Some situations, conditions, services and expenses are not covered under any part of the Plan.
Any expense not specifically included as a Covered Service is not covered under the Plan.
3
BENEFIT LIMITATIONS
Pre-Existing Conditions
Exclusion
HIPAA Certificates of
Creditable Coverage
Do Not Apply
A 270-day waiting period for treatment of Pre-Existing Conditions applies when a
Member becomes covered under the Plan and upon reinstatement of coverage. The
USA Health Plan has elected not to participate in the federal Health Insurance
Portability and Accountability Act (HIPAA). Certificates of Creditable Coverage
from a previous health plan will not be accepted to offset the Pre-Existing Conditions
Exclusion under this Plan.
Mental Health Treatment
and Substance Abuse
Treatment
Inpatient Mental Health and Substance Abuse Treatment is limited to a Calendar
Year Maximum Benefit of 30 days and a Lifetime Maximum Benefit of 60 days.
Outpatient Mental Health and Substance Abuse Treatment is limited to a Calendar
Year Maximum Benefit of 40 visits. Substance Abuse Treatment is limited to a
Lifetime Maximum Benefit of $25,000.
Temporomandibular Joint
(TMJ) Related Disorders
Coverage of treatment for TMJ disorders is limited to Phase I category services, as
approved by the American Academy of Craniomandibular Disorders and surgical
services involving the mandible and maxilla when TMJ is diagnosed.
Orthognathic Surgery
Orthodontic and periodontic services required after orthognathic surgery are limited
to a Lifetime Maximum Benefit of $4,000.
Chiropractic Services
All chiropractic services are limited to a $1,000 Calendar Year Maximum Benefit.
Physical, Occupational
and Speech Therapy
Physical therapy, occupational therapy and speech therapy are limited to a Calendar
Year Maximum Benefit of 60 treatment sessions each.
Home Health Care
Home Health Care, which includes Skilled Nursing Care, Durable Medical
Equipment, and Home Care Medical Supplies, is limited to a $30,000 Calendar Year
Maximum Benefit.
Extended Care Facility
Benefits for an inpatient stay at an Extended Care Facility are limited to a Calendar
Year Maximum Benefit of 60 days.
Hospice Care
Hospice Care for a Member who is Terminally Ill is limited to a Lifetime Maximum
Benefit of 180 days.
Organ Transplant Benefit
Benefits are provided for specific organ and tissue transplants, under specific
circumstances and when approved by the Claims Administrator in advance.
Lifetime and Calendar Year Maximum Benefit amounts apply even if coverage is terminated and reinstated, or if
the Member is covered at one time as an Eligible Dependent and at another time as an Eligible Employee.
GENERAL PLAN PROVISIONS
Pre-Certification
Pre-Certification is required for all Hospital admissions, for organ transplants, and
for Home Health Care and Hospice Care. A $400 penalty will be imposed for failure
to Pre-Certify any Hospital admission.
Claims Filing Deadline
Claims must be filed within 12 months of the date of service to be eligible for
payment. In most cases, your Blue Cross and Blue Shield Provider will file the claim
for you. Some claims must be filed by the Member.
Allowed Amount
Claims for Covered Services are paid at a benefit percentage of the Allowed Amount,
as determined by the Claims Administrator. Charges in excess of the Allowed
Amount may be the responsibility of the Member, unless provided by a Blue Cross
and Blue Shield Provider.
Coordination of Benefits
When other group insurance coverage is in effect, the Plan will coordinate benefits.
Subrogation
The Plan reserves the right to recover from a responsible third party.
4
EMPLOYEE AND MEMBER RESPONSIBILITY
RESPONSIBILITIES TO THE PLAN
Employees and Eligible Dependents have obligations to the USA Health & Dental Plan. These responsibilities
are designed to ensure all benefits and eligibility rules are applied equally and fairly to all participants. It is
important that you fulfill your responsibility in part by reading this Member Handbook. It will fully explain your
rights to benefits and your obligations to the Plan.
EMPLOYEE RESPONSIBILITIES
MEMBER RESPONSIBILITIES
1. Each Employee is responsible for providing to
the Human Resources Department and the
Claims Administrator the information necessary
for the purpose of administering the Plan and its
provisions. Payment of benefits is conditioned
upon the Plan promptly receiving the complete
information necessary to provide benefits.
Each Member is responsible for adhering to the
following requirements:
1. Carefully reading this Member Handbook to
ensure an understanding of the Plan’s eligibility
rules, benefits, provisions and limitations, and
how benefits are paid.
2. Checking with the medical provider prior to
receiving any services to verify the provider is a
Network Provider.
2. The Employee is responsible for submitting
written Application for coverage under the Plan,
on the Application form provided by the Human
Resources Department. An Application must
also be submitted to add or remove dependents.
Addition or removal of dependents under the
Plan is not done automatically, and can be
accomplished only through proper completion
and acceptance of the Application by the Human
Resources Department.
3. Following requirements for Pre-Certification
when required.
4. Filing a claim, if required, within 12 months of
the date of service. Refer to the section titled
How to File a Claim for Benefits for additional
information.
5. Assisting the Claims Administrator with
coordination of benefits, the Plan’s right of
subrogation, right of reimbursement and right of
recovery of payments made in error. Payment of
benefits is conditioned upon the Plan promptly
receiving the complete information necessary to
provide benefits.
3. Application must be filed with the Human
Resources Department within 30 days of
employment or within 30 days of a Change-InStatus Event.
4. Additional information requested by the Human
Resources Department must be provided in
writing on the forms obtained from the Human
Resources Department. This information will be
deemed to be filed on the date it is actually
received by the Human Resources Department.
6. Timely notification to the Human Resources
Department when a Member ceases to be an
Eligible Dependent.
7. Following the requirements for claim review
when a claim has been denied.
5. The Employee is responsible for notifying the
Human Resources Department of any ChangeIn-Status Event. Failure to report an event
causing the dependent to cease as an Eligible
Dependent will result in the Employee becoming
liable for benefits paid by the Plan on behalf of
that individual. For example, a divorced spouse
has coverage terminated the first of the month
following the date of the divorce. An Employee
who fails to notify the Human Resources
Department of a divorce will be responsible for
reimbursing the University of South Alabama
for any benefits paid for services of the divorced
spouse incurred after that date.
Failure to fulfill your obligations to the Plan may
result in the denial of benefits in whole or in part or
your financial liability to reimburse the Plan for any
benefits paid due to your failure to provide required
information to the Plan in a timely manner.
5
ELIGIBILITY AND ENROLLMENT
PARTICIPATION
4. A child who permanently resides in your home
and over whom you have legal guardian status
by court appointment because the child’s parents
are dead or have had their parental rights
terminated by court action.
You may join the USA Health & Dental Plan if you
are a University of South Alabama Employee. An
Employee is defined as one who has a specific
appointment with no termination date, occupies a
permanently budgeted position, and works a
minimum of 20 hours per week on a regular basis.
5. A child for whom you are legally required to
provide health insurance coverage during the
period specified in a Qualified Medical Child
Support Order (QMCSO).
ELIGIBLE EMPLOYEES
In all cases, the Employee must provide a minimum
of one-half (50%) of the child’s financial support.
An Employee becomes an Eligible Employee by
making proper and timely Application for coverage
to the Human Resources Department. Proper
Application includes the required authorization for
payroll deduction of the Employee Contribution.
Coverage is contingent upon approval by the Human
Resources Department and is evidenced by issuance
of an identification card or some other written
notification of coverage.
The Employee must provide acceptable written
documentation within 30 days, when requested by
the Human Resources Department, to support a
claim of Eligible Dependent status. Failure to
provide the required proof of dependency will result
in the dependent not being covered.
APPLICATION FOR COVERAGE
FOR NEW EMPLOYEES
ELIGIBLE DEPENDENTS
Eligible Dependents include:
1. Your legal spouse of the opposite sex.
You must complete an Application and file it with
the Human Resources Department within 30 days of
your first day of employment. You may elect to
cover your Eligible Dependents at this time.
Eligible Dependents include only those persons
listed on the Application form and accepted by the
Human Resources Department.
2. Your unmarried child under the age of 19.
3. Your unmarried child between the ages of 19
and 25 who is a Full-Time Student and who is
not employed on a regular full-time basis.
Upon enrollment, you authorize the Payroll
Department to deduct the Employee Contribution
from your pay check. You will also be enrolled in
the Section 125 Premium Conversion Plan, which
allows Eligible Employees to pay the Employee
Contribution with pre-tax dollars, unless you opt-out
of enrollment in the Premium Conversion Plan.
4. Your unmarried Disabled child of any age,
provided the Disability commenced prior to age
19. Coverage under the Plan continues without
interruption for the duration of the Disability so
long as the Employee maintains Dependent
Coverage.
An unmarried child may include:
1. Your natural-born or legally adopted child,
including a legally adopted child living with you
as the adopting parent during a period of
probation.
IMPORTANT NOTICE FOR NEW EMPLOYEES
Federal law allows non-federal government plans the
right to be exempt from the Health Insurance
Portability and Accountability Act (HIPAA). New
Employees and their Eligible Dependents are
required to serve a 270-day Pre-Existing Conditions
Exclusion waiting period, as explained in this
Member Handbook. Certificates of prior coverage
from your previous insurance plan will not be
accepted to reduce the Pre-Existing Conditions
Exclusion waiting period. All new employees are
encouraged to continue the COBRA privilege
granted under a previous employer’s health plan.
2. Your stepchild who is not covered by any other
group medical insurance or reimbursement
program and who permanently resides in your
home.
3. A child who is not your foster child, but who
permanently resides in your home and over
whom you have legal custody by court
appointment.
6
OPEN ENROLLMENT PERIOD
meeting or no longer meeting the definition of a
Full-Time Student, or child becoming eligible
under another health plan).
There is a one-month Open Enrollment Period,
usually the month of November, during which an
Employee may enroll in the USA Health & Dental
Plan and/or add Eligible Dependents. During this
period you may file an Application with the Human
Resources Department and coverage will begin on
the first day of the following Calendar Year.
7. An end to the Disability of a Disabled child
enrolled as your dependent under the Plan.
8. A change in your residence or work site, or that
of a spouse or dependent, which affects ability to
access benefits under this or another employersponsored health plan.
Employees and/or Eligible Dependents who enroll
during the Open Enrollment Period will be subject to
the 270-day Pre-Existing Conditions Exclusion
waiting period, as explained in this Member
Handbook.
9. A change required by a court order.
10. Your, or your dependent’s, eligibility for
Medicare or Medicaid.
The change in coverage must be consistent with the
Change-In-Status Event, and you must provide
written documentation, upon request, to verify the
Change-In-Status Event.
SPECIAL ENROLLMENT PERIOD DUE TO
CHANGE-IN-STATUS EVENTS
You may also enroll in the Plan, enroll your Eligible
Dependents or terminate coverage for yourself or a
dependent when certain events cause a Change-InStatus. To make an enrollment change due to a
Change-In-Status Event, you must make Application
to the Human Resources Department within 30 days
of the event.
For Employees and/or Eligible Dependents enrolling
during the Special Enrollment Period, the PreExisting Conditions Exclusion waiting period may
be waived in whole or in part by receiving credit for
the period of time the Employee has been employed
in a benefits-eligible position.
A Change-In-Status Event, which would allow you
to make changes to your enrollment in the Plan
within 30 days is deemed to have occurred upon:
DUPLICATE COVERAGE EXCLUDED
If both you and your spouse are eligible for the USA
Health & Dental Plan as Employees:
1. Both Employees may elect single coverage, or
1. A change in your marital status (marriage,
divorce, legal separation or death of your
spouse).
2. One Employee may elect Dependent Coverage
and the spouse may be covered as an Eligible
Dependent.
2. A change in the number of your dependents
(birth or adoption of a child, death of a child,
obtaining legal custody or legal guardianship).
Under no circumstances may both Employees elect
Dependent Coverage or an Employee be covered as
both an Eligible Employee and as an Eligible
Dependent.
3. A change in your, or your spouse’s, employment
status (starting/ending employment, changing
from part-time to full-time or vice versa, a strike
or lock-out, or taking or returning from an
unpaid leave of absence or leave under the
Family and Medical Leave Act or USERRA
during which your, or your spouse’s, coverage
terminated).
WHEN COVERAGE BEGINS
Enrollment requires completion of an Application.
If your employment begins on the first day of the
calendar month, your coverage will begin on the first
day of that month. If your employment begins on a
day other than the first day of the calendar month,
your coverage will begin on the first day of the
month following.
4. Exhaustion of your coverage period under a
previous employer’s COBRA continuation.
5. A significant change in the cost of or coverage
provided by your spouse’s employer-sponsored
health plan, or a significant change in the cost of
or coverage provided by this Plan.
If you fail to make proper Application to the
Human Resources Department within 30 days of
your first day of employment, you must wait until
the Open Enrollment Period to apply for
6. A change in the eligibility status of a dependent
child (marriage of the child, child reaching the
maximum age for coverage under the Plan, child
7
5. The day the Plan is terminated or coverage for a
class of Members is terminated.
coverage beginning the first day of the following
Calendar Year.
Eligible Dependents will be covered on the date you
become covered, assuming you have filed an
Application for Dependent Coverage that has been
accepted by the Human Resources Department.
Dependent Coverage will end at 12:01 a.m.:
1. The day the Employee’s coverage terminates.
2. The first day of the month following the date the
individual no longer meets the definition of an
Eligible Dependent, which includes the:
If you enroll during the Open Enrollment Period,
normally held in the month of November, coverage
will begin on January 1st of the following Calendar
Year. Dependent Coverage may also be added
during the Open Enrollment Period, to be effective
on the first day of the following Calendar Year.
a) Date of divorce for your divorced spouse;
b) Date of marriage for your married child;
c) Date your unmarried child attains age 19; or
age 25 if a Full-Time Student.
A new Eligible Dependent will be covered on the
date they become your dependent if you make
Application within 30 days of this Change-In-Status
Event. If the new Eligible Dependent is not added
within that 30-day period you will be required to
wait until the next Open Enrollment Period to add
your new Eligible Dependent for coverage effective
on the first day of the following Calendar Year.
3. The first day of the month for which you fail to
make payment of the Employee Contribution for
Dependent Coverage.
4. When you fail to provide information to verify
dependent status within 30 days of receipt of a
request for verification from the Human
Resources Department or Claims Administrator;
in such case, coverage terminates retroactive to
the earliest date it is determined the individual
ceased to be an Eligible Dependent.
For Change-In-Status Events other than the addition
of a new Eligible Dependent by virtue of marriage,
birth, adoption or a QMCSO, coverage is effective
the first of the month following approval of the
Application. Application must be made during the
30-day Special Enrollment Period following the
event.
A dependent who loses coverage under the Plan is
eligible for COBRA continuation of coverage only if
the Human Resources Department is notified in
writing within 60 days of the event that caused the
individual to no longer meet the definition of an
Eligible Dependent.
Coverage will terminate
retroactively to the first of the month following the
event, but COBRA continuation of coverage is
provided only if the Human Resources Department
is notified within 60 days of the event.
If you or an Eligible Dependent are confined in a
hospital on the Effective Date, coverage will not
begin until confinement ends. This does not apply
to a newborn child of an Eligible Employee or a
newborn adopted child of the Eligible Employee,
provided Application is made within 30 days of the
child’s birth, adoption or placement for adoption.
If coverage for a spouse is terminated due to divorce,
and an Eligible Employee is required by the terms of
the divorce judgment to provide health insurance
coverage for the divorced spouse, coverage may be
provided under this Plan only under COBRA
continuation of coverage. The divorced spouse is no
longer an Eligible Dependent under this Plan and
may continue coverage only through COBRA. If
notice to the Human Resources Department is not
made within 60 days of the date of divorce, COBRA
continuation of coverage will not be available to the
divorced spouse.
WHEN COVERAGE TERMINATES
Coverage under the Plan will end at 12:01 a.m.:
1. The first day of the month following the month
in which you cease to be an Employee, or your
employment status changes so that you are no
longer considered to be an Employee.
2. The first day of the month for which you fail to
make payment of the Employee Contribution.
3. The first day of the month for which a Member
fails to make timely payment of the required
COBRA premium.
CONTINUATION WHILE ON APPROVED LEAVE
An Eligible Employee will continue to be eligible
for coverage while in paid status on payroll during a
period of paid sick, vacation or personal leave, or
4. The day you enter full-time military service,
except as provided under Uniformed Services
Leave, as explained in this Member Handbook.
8
3. For all dependents, the first day of the month
following the date the surviving spouse
remarries.
while on unpaid Family and Medical Leave or
Uniformed Services Leave, provided the Eligible
Employee has qualified for such leave and complied
with the leave requirements, including payment of
the Employee Contribution.
4. For all dependents, the first day of the month
following the date the surviving spouse becomes
eligible for other group health coverage.
An Eligible Employee will continue to be eligible
for coverage while on unpaid personal leave. The
monthly premium required for continued coverage is
the applicable funding rate with no Employer
Contribution.
5. For all dependents, the first day of the month
following the date the surviving spouse becomes
eligible for Medicare.
6. The date the Plan is amended to terminate the
Surviving Dependent health benefit, or the date
the Plan is terminated.
Failure to pay the required Employee Contribution
in a timely manner will result in termination of
coverage, and coverage may be reinstated only when
the Employee returns to paid status and pays any
Employee Contributions due, subject to all Plan
provisions and limitations.
The months of coverage provided under this
Surviving Dependent benefit will be considered to
run concurrent with COBRA. When a dependent’s
coverage is terminated for one of the reasons listed,
the dependent may be eligible to elect COBRA
continuation of coverage for any months remaining
under COBRA.
If an Employee does not return to paid status, the
continuation of coverage while on unpaid personal
leave will be considered to run concurrent with
COBRA. The Employee may be eligible to elect
COBRA continuation of coverage for any months
remaining under COBRA.
LEGAL PROTECTION FOR
CONTINUATION OF COVERAGE
SURVIVING DEPENDENT BENEFIT
There are several conditions under which a
Member’s health and dental benefits may be
continued beyond the date coverage would otherwise
terminate. Refer to the sections in this Member
Handbook concerning COBRA continuation of
coverage, Family and Medical Leave (FMLA) and
Uniformed Services Leave (USERRA) for
circumstances that allow for a limited continuation
of a Member’s coverage.
The Eligible Dependents of an Employee covered
under the Plan at the time of the Employee’s death
may continue coverage under the Plan. The Eligible
Dependents must request coverage under this
Surviving Dependent benefit within 60 days of the
date of termination of coverage by making
Application to the Human Resources Department.
The monthly premium required for continued
coverage is the applicable funding rate with no
Employer Contribution.
ACTIVE EMPLOYEES ELIGIBLE FOR MEDICARE
This benefit is available only if the Surviving
Dependents are not eligible for enrollment in any
other group health plan, including that provided by a
Surviving Dependent’s employer, or Medicare.
If you continue to be an Employee of the University
of South Alabama when you are age 65 or older, or
are otherwise eligible for Medicare, you and your
Eligible Dependent(s) will continue to be covered
under the same eligibility rules and for the same
benefits available to Employees under age 65.
If the Eligible Dependents of a deceased Employee
are not eligible for continuation of coverage under
this Surviving Dependent benefit, coverage may be
continued under COBRA.
This Plan will be primary over Medicare and will
provide benefits for Covered Services first.
Medicare will then pay for Medicare eligible
expenses, if any, not paid by this Plan. This rule
applies to Eligible Employees eligible for Medicare
and any Eligible Dependents who are eligible for
Medicare.
Coverage may be continued until the earlier of:
1. The first day of the month for which the
applicable monthly premium is not paid within
the 30-day grace period.
2. The first day of the month following the date on
which the Surviving Dependent no longer meets
the definition of an Eligible Dependent.
9
There is one exception to this policy: If an Eligible
Employee or Eligible Dependent becomes eligible
for Medicare benefits based solely on End Stage
Renal Disease (ESRD), this Plan will be primary for
If you do not enroll in Medicare Part B or Medicare
Part D when you are initially eligible, you can enroll
in Part B or Part D during Medicare’s special
enrollment period, which begins the month your
employment ends or the month you are no longer
covered under the USA Health & Dental Plan,
whichever is later. Be sure to enroll right away
because Social Security charges a late enrollment
penalty if you wait more than 30 days after your
coverage under an employer-sponsored plan ends.
the first 30 months of eligibility for Medicare. After
the first 30 months of eligibility for Medicare, if the
Eligible Employee or Eligible Dependent is still
eligible for Medicare due to ESRD or for any other
reason, Medicare will be primary.
Employees and/or their Eligible Dependents may
enroll in Medicare Parts A (hospitalization) and B
(physician services) at the time they become eligible
for Medicare. If you are eligible, you should enroll
in Medicare Part A, which is premium-free. There
are also some advantages of enrolling in Medicare
Part B when you are eligible.
TERMINATION AND REINSTATEMENT
Employees and/or their Eligible Dependents who
have been covered under the Plan, and have had
their coverage terminate for one of the reasons listed
previously, will be eligible for reinstatement of
coverage under certain conditions, such as reemployment or enrollment during the Open
Enrollment or Special Enrollment Periods.
Effective January 1, 2006, you may also enroll in
Medicare Part D (prescription drugs) if you are
eligible for Medicare. Refer to the section titled
“Creditable Drug Coverage Notice” for additional
information.
When a Member’s coverage terminates and is
reinstated, the Pre-Existing Conditions Exclusion
will apply. The Lifetime and Calendar Year
Maximum Benefits will apply even if coverage is
terminated and reinstated.
Lifetime and Calendar Year Maximum Benefits
apply if the Member is covered at one time as an
Eligible Dependent and at another time as an
Eligible Employee.
10
HEALTH PLAN BENEFITS
FREEDOM OF CHOICE
BENEFIT LEVELS
The USA Health Plan offers benefits designed to
provide you with freedom of choice when selecting
medical providers. The Plan allows you and your
Eligible Dependents to select any Blue Cross and
Blue Shield Provider when medical care is needed.
Referrals are not required to see a specialist.
The level of benefits you receive under the USA
Health Plan will vary depending on whether you
receive care from a Blue Cross and Blue Shield
Provider or a USA Health System Provider. You
will receive benefits at a lower cost if you receive
medical attention from a USA Health System
Provider. You should become familiar with the
following terms and the benefits available:
Blue Cross and Blue Shield Providers include a wide
selection of Physicians, Hospitals and other
providers. Within this network of Blue Cross and
Blue Shield Providers are Physicians, Hospitals and
other providers affiliated with the University of
South Alabama. These are called USA Health
System Providers.
BLUE CROSS AND BLUE SHIELD PROVIDER – A
Hospital, Physician or other medical provider
affiliated with Blue Cross and Blue Shield of
Alabama. Outside Alabama, Blue Cross and Blue
Shield Providers are members of the BlueCard PPO
network.
When medical care is needed, you may elect at the
point of service to use any Blue Cross and Blue
Shield Provider, including USA Health System
Providers. The decision is made at the time you need
medical care. There is no annual election of one or the
other.
USA HEALTH SYSTEM PROVIDER – A Hospital,
Physician or other medical provider affiliated with
the University of South Alabama. These services
are provided at the lowest cost to you. The higher
level of benefits available under the USA Health
System do not apply when you use any other
provider, regardless of the situation and regardless of
whether or not the service is available from a USA
Health System Provider.
The benefits applicable to medical care received and
expenses incurred when using a Blue Cross and Blue
Shield Provider, including a USA Health System
Provider, are described in this Member Handbook.
It is your responsibility to read this Member
Handbook and review these benefits.
BLUECARD PPO WORLDWIDE – A network of
providers affiliated with Blue Cross and Blue Shield,
in every state in the United States and in many
countries internationally. If you seek medical
attention outside Alabama, you may locate a
BlueCard PPO member by calling the toll-free
number on the back of your ID card.
ABOUT BLUE CROSS AND BLUE SHIELD
PROVIDERS
Blue Cross and Blue Shield uses its purchasing
power to negotiate with health care providers.
Negotiated savings are passed on to you through
increased benefits when you use a provider who is a
member of this network. The Plan contracts with
Blue Cross and Blue Shield of Alabama to manage
the network and to pay claims. Outside Alabama, the
provider of medical care must be a BlueCard PPO
member or benefits may be reduced or not covered.
OUT-OF-NETWORK - Services that are not received
from a Blue Cross and Blue Shield Provider will be
covered at a reduced level of benefits, and some
services are not covered unless received from a Blue
Cross and Blue Shield Provider.
PROVIDER DIRECTORIES
Directories listing the Hospitals, Physicians,
pharmacies, outpatient clinics and other providers
participating in the USA Health Plan are online at
www.usahealthsystem.com and www.bcbsal.com.
From time to time providers are added and deleted
from the network. It is your responsibility to check
with your provider prior to treatment to determine
that the provider is still a Blue Cross and Blue
Shield Provider or USA Health System Provider.
ABOUT USA HEALTH SYSTEM PROVIDERS
USA Health System Providers currently include the
USA Medical Center, USA Children’s and Women’s
Hospital, Infirmary West, USA Physicians Group,
and other providers whose participation allows the
Plan to charge a lower Copay when you use a USA
Health System Provider.
11
USA HEALTH PLAN
BENEFITS
FOR
COVERED SERVICES
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
Refer to the section titled Health Plan Covered Services for a detailed list of services covered by the Plan. These are
Covered Services to the extent they are not limited or excluded by any provisions of the Plan and are Medically
Necessary. Covered Services are subject to the Allowed Amount and Maximum Benefit limitations.
INPATIENT HOSPITAL BENEFITS
Pre-Admission Certification is required for all Hospital admissions, except maternity admissions. Emergency
admissions must be Certified within 48 hours. If you are unable to communicate, someone may call for you. If you
are unable to communicate and no one is available to call for you, the deadline for Pre-Certification is extended to 48
hours after you regain the ability to communicate. You should check with your admitting Physician to ensure your
admission has been Pre-Certified. A $400 penalty will be imposed for failure to Pre-Certify any Hospital
admission. The Inpatient Hospital Deductible is waived if you are re-admitted to a Hospital within 31 days of your
discharge, for the same diagnosis.
$500 Deductible;
$50 per day Copay for days 2-5
Deductible and Copay
No Deductible;
No Copay
Inpatient facility coverage
(including maternity admissions)
After the inpatient Hospital Deductible and daily Copay, if applicable, the
Plan pays 100% for semi-private room and board, intensive care units,
general nursing services and usual hospital ancillaries
Emergency Admissions
In cases of Emergency Admission, the inpatient Hospital Deductible and
daily Copay are waived for all non-USA Hospitals except those in the city
of Mobile. The member must be admitted through the emergency room,
requiring immediate medical intervention as a result of a severe, life
threatening or potentially disabling condition (a type 1 emergency)
OUT-OF-NETWORK INPATIENT HOSPITAL BENEFITS
In Alabama, inpatient Hospital benefits are paid only if received from a Blue Cross and Blue Shield Provider.
Outside Alabama, inpatient Hospital benefits are paid only if received from a BlueCard PPO Provider, except for
cases of Injury or Medical Emergency. Members may locate a BlueCard PPO Provider by calling the toll-free
number on the back of the ID card.
EXTENDED CARE FACILITY BENEFITS
Extended Care Facility
Plan pays 100%, limited to a Calendar Year Maximum Benefit of 60 days
HOSPICE BENEFITS
Hospice Care
Plan pays 100%, limited to a Lifetime Maximum Benefit of 180 days
12
BENEFITS
FOR
COVERED SERVICES
USA HEALTH PLAN
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
OUTPATIENT HOSPITAL BENEFITS
Benefits listed below are for outpatient Hospital facility services. Physician services are billed separately.
Outpatient surgery
Medical Emergency
Injury
Diagnostic lab tests and pathology
Plan pays 100% after $150 Copay
Plan pays 100%; no Copay
Plan pays 100% after $150 Copay; Plan pays 100% after $25 Copay;
Copay waived if admitted within 24 Copay waived if admitted within 24
hours
hours
Plan pays 100% when services are received within 72 hours of the Injury;
thereafter, covered at 80% subject to the $250 Calendar Year Deductible
Plan pays 100% after $5 Copay for
each test
Plan pays 100%; no Copay
Diagnostic imaging, including xrays, CT scan, MRI, PET scan
Plan pays 100% after $50 Copay
Plan pays 100%; no Copay
Hemodialysis, peritoneal dialysis,
IV therapy, chemotherapy, radiation
therapy
Plan pays 100% after $25 Copay
Plan pays 100%; no Copay
OUT-OF-NETWORK OUTPATIENT HOSPITAL BENEFITS
In Alabama, outpatient Hospital benefits are paid only if received from a Blue Cross and Blue Shield Provider,
except for cases of Injury or Medical Emergency.
Outside Alabama, outpatient Hospital benefits are paid only if received from a BlueCard PPO Provider, except for
cases of Injury or Medical Emergency. Members may locate a BlueCard PPO Provider by calling the toll-free
number on the back of the ID card.
USE OF AN EMERGENCY ROOM
Use of an emergency room is limited to a Medical Emergency or Injury. Symptoms must be of sufficient severity
that the Member could reasonably expect the absence of immediate medical attention to result in jeopardy to life
or health, serious impairment of bodily functions or serious dysfunction of a bodily organ. The Claims
Administrator will recognize as a Medical Emergency only emergency room treatment coded by the treatment
facility with a “type 1 emergency” or “type 2 urgent care condition” code. The code is based on the primary
diagnosis (usually the final diagnosis, not the presenting symptoms). Use of an emergency room for treatment
that is not a Medical Emergency or Injury, as determined by the Claims Administrator, will be paid according to
the Major Medical benefits schedule, at 80% subject to the $250 Calendar Year Deductible.
13
BENEFITS
FOR
COVERED SERVICES
USA HEALTH PLAN
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
Physician office visits and
outpatient consultations
Plan pays 100% after $25 Copay
Plan pays 100% after $10 Copay
Physician services for treatment of
an Injury or Medical Emergency
Plan pays 100% after $25 Copay
Plan pays 100% after $10 Copay
PHYSICIAN BENEFITS
Surgery and anesthesia
Plan pays 100%; no Copay
Inpatient Physician visits, second
surgical opinions and inpatient
consultations
Plan pays 100%; no Copay
Maternity care
Plan pays 100%; no Copay
Diagnostic x-ray
Plan pays 100%; no Copay
Diagnostic lab tests and pathology /
results generated by Physician’s
office
Plan pays 100%; no Copay
Plan pays 100%; no Copay
Diagnostic lab tests and pathology /
results generated by outpatient
department or independent lab
Plan pays 100% after $5 Copay for
each test
Plan pays 100%; no Copay
OUT-OF-NETWORK PHYSICIAN BENEFITS
In Alabama, Physician benefits are paid only if received from a Blue Cross and Blue Shield Provider, except for
cases of Injury or Medical Emergency.
Outside Alabama, Physician services not received from a BlueCard PPO Provider will be covered at 80% of the
Allowed Amount, subject to the $250 Calendar Year Deductible. Members may locate a BlueCard PPO Provider
by calling the toll-free number on the back of the ID card.
TEMPOROMANDIBULAR JOINT RELATED DISORDERS
The Plan pays 100% for treatment of TMJ related disorders, subject to all provisions and limitations of the Plan.
Coverage is limited to Phase I treatment, as approved by the American Academy of Craniomandibular Disorders,
and surgical services involving the mandible and maxilla when TMJ is diagnosed. Phase I includes diagnosis and
initial treatment including examination, x-rays and study casts, TMJ joint repositioning appliances, removable or
fixed (limited to one every three years), and six office visits every three years.
14
USA HEALTH PLAN
BENEFITS
FOR
COVERED SERVICES
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
PRESCRIPTION DRUG CARD BENEFITS
Only legend drugs prescribed by a Physician and dispensed by a licensed pharmacist are eligible for benefits.
Blue Cross and Blue Shield Provider pharmacies maintain a list of Preferred Brand Name drugs. Diabetic supplies
and oral contraceptives are included in this benefit, as explained under the section titled Other Covered Services.
Prescriptions will be dispensed up to a maximum of a 34-day supply, unless the prescription is considered a
maintenance drug, in which case it may be dispensed up to a maximum of a 90-day supply or 100 unit doses; the
Copay applies to each 30-day supply. Blue Cross and Blue Shield Provider pharmacies have a list of maintenance
drugs. There are no benefits for drugs purchased from a non-participating pharmacy in the state of Alabama.
Prescription drugs purchased from a non-participating pharmacy out of state or out of the country will be
processed at the participating pharmacy allowance plus the applicable Copay. The Member will be responsible
for any cost over the participating pharmacy allowance plus the applicable copayment. The Member must file a
claim including the pharmacy receipts.
Calendar Year Deductible
The Calendar Year Prescription Deductible is $50, limited to a maximum of
three per family (when three $50 Deductibles have been met during a
Calendar Year, no other family Members must meet the Deductible). After
the Calendar Year Prescription Deductible has been met the Plan pays:
Generic
100% after $10 Copay
Preferred Brand Name
100% after $25 Copay
Non-Preferred Brand Name
100% after $35 Copay
HOME HEALTH CARE BENEFITS
Benefits for Home Health Care are not provided Out-of-Network.
All Home Health Care services require Pre-Certification.
Home Health Care
Plan pays 100%, limited to a Calendar Year Maximum Benefit of $30,000.
Home Health Care includes Skilled Nursing Care, Durable Medical
Equipment and Home Care Medical Supplies
MENTAL HEALTH TREATMENT AND SUBSTANCE ABUSE TREATMENT BENEFITS
Mental Health and Substance Abuse Treatment must be rendered or prescribed by a psychiatrist, psychologist,
Licensed Professional Counselor or Licensed Clinical Social Worker. All Substance Abuse Treatment is limited
to a Lifetime Maximum Benefit of $25,000. Pre-Admission certification is required for Inpatient Hospital
treatment.
Inpatient Hospital treatment
Physician inpatient treatment
Physician outpatient treatment
Plan pays 80% of the Allowed Amount, subject to $250 Calendar Year
Deductible; limited to a Calendar Year Maximum Benefit of 30 days and a
Lifetime Maximum Benefit of 60 days
Plan pays 80% of the Allowed Amount, subject to $250 Calendar Year
Deductible; limited to a Calendar Year Maximum Benefit of 40 visits
15
BENEFITS
FOR
COVERED SERVICES
USA HEALTH PLAN
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
MAJOR MEDICAL BENEFITS
Major Medical benefits are paid at a percentage of the Allowed Amount for Covered Services after the Member
has met a $250 Calendar Year Deductible. After the Member has paid the $250 Calendar Year Deductible, the
Plan pays 80% of the first $6,000 of the Allowed Amount for Covered Services, after which the payment
percentage increases to 100% of the Allowed Amount for the remainder of that Calendar Year. Out-of-Network
expenses are always paid at 80% of the Allowed Amount; the 100% benefit level does not apply to Out-ofNetwork Covered Services. The charges for Covered Services in excess of a Maximum Benefit, or in excess of
the Allowed Amount, are the responsibility of the Member.
Ambulance service
Plan pays 80%, subject to $250 Calendar Year Deductible
Allergy testing and treatment
Plan pays 80%, subject to $250 Calendar Year Deductible
Chiropractic treatment
Plan pays 80%, subject to $250 Calendar Year Deductible;
limited to a $1,000 Calendar Year Maximum Benefit
Occupational therapy,
Physical therapy and
Speech therapy
Cardiac rehabilitation
Plan pays 80%, subject to $250
Calendar Year Deductible; limited to
a Calendar Year Maximum Benefit of
60 sessions each
Plan pays 100% after $10 Copay, not
subject to Calendar Year Deductible;
limited to a Calendar Year Maximum
Benefit of 60 sessions each
Plan pays 80%, subject to $250 Calendar Year Deductible; limited to a
Maximum Benefit of 36 treatment sessions per cardiac episode
OUT-OF-NETWORK MAJOR MEDICAL BENEFITS
In Alabama, Major Medical benefits are paid only if received from a Blue Cross and Blue Shield Provider.
Ambulance service not received from a Blue Cross and Blue Shield Provider will be covered at 80% of the
Allowed Amount, subject to the $250 Calendar Year Deductible.
Outside Alabama, Major Medical services not received from a BlueCard PPO Provider will be covered at 80% of
the Allowed Amount, subject to the $250 Calendar Year Deductible.
BLUECARD PPO WORLDWIDE
The BlueCard PPO program is a worldwide network of Blue Cross and Blue Shield preferred providers. The
BlueCard Worldwide program provides coverage not only for emergency care, but also for inpatient, outpatient, and
professional services. For inpatient services, participating Hospitals will file claims. The member is responsible only
for applicable Deductibles and Copays. For outpatient and professional services, the member is responsible for
paying the provider and filing the claim. The member is reimbursed in full less any applicable Deductibles and
Copays. If a member chooses to see a non-participating provider he or she may be responsible for the provider's
normal charges.
16
BENEFITS
FOR
COVERED SERVICES
USA HEALTH PLAN
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
PREVENTIVE CARE SERVICES
Benefits for preventive care services are available only when rendered by a Blue Cross and Blue Shield Provider.
Inpatient Physician visit for routine
newborn care
Plan pays 100%, no Copay; limited to one inpatient exam
Routine well child examinations,
birth through age 6
Plan pays 100% after $25 Copay;
limited to 9 visits during the first 2
years of the child’s life and then one
visit each Calendar Year thereafter
through age 6
Plan pays 100%, no Copay; limited
to 9 visits during the first 2 years of
the child’s life and then one visit
each Calendar Year thereafter
through age 6; $10 Copay may
apply to other medical services
received during office visit
Periodic health assessment,
including complete blood count,
urinalysis, TB skin test
Plan pays 100% after $25 Copay;
limited to one exam every two
Calendar Years for Members age 7
through 34, and one exam each
Calendar Year for Members age 35
and older
Plan pays 100%, no Copay; limited
to one exam every two Calendar
Years for Members age 7 through
34, and one exam each Calendar
Year for Members age 35 and older;
$10 Copay may apply to other
medical services received during
office visit
Routine immunizations
Plan pays 100% after Physician office visit Copay if applicable
Routine pap smear
Plan pays 100% after Physician office visit Copay if applicable; limited to
one per Calendar Year
Routine mammogram
Plan pays 100% after Physician office visit Copay if applicable; limited to
one exam for women between the ages of 35 and 39 and one per year for
women age 40 and over
Routine prostate specific antigen
Plan pays 100% after Physician office visit Copay if applicable; limited to
one per year for males age 40 and over
Routine cholesterol test
Plan pays 100% after Physician office visit Copay if applicable; limited to
one every 5 Calendar Years for Members age 18 and older
Colorectal cancer screening
Plan pays 100% after Physician office visit Copay if applicable; limited to
Members age 50 and over, including: one fecal occult blood test each
Calendar Year; one flexible sigmoidoscopy every three Calendar Years;
one double-contrast barium enema every five Calendar Years; one
colonoscopy every 10 Calendar Years
Routine vision exam
Plan pays 100% after $25 Copay; limited to one per Calendar Year
17
BENEFITS
FOR
COVERED SERVICES
USA HEALTH PLAN
BLUE CROSS AND BLUE
SHIELD PROVIDERS
USA HEALTH SYSTEM
PROVIDERS
BABY YOURSELF
Baby Yourself is a managed care program for Pregnant Members that offers individual management by a registered
nurse. As soon as you find out you are Pregnant, contact Blue Cross and Blue Shield of Alabama at (205) 733-7818
or 1-800-222-4379, and a nurse will be assigned to manage your prenatal care throughout your Pregnancy.
INDIVIDUAL CASE MANAGEMENT
If you have a catastrophic, long-term or chronic Illness or Injury, a Blue Cross registered nurse may assist you in
accessing the most appropriate health care for your condition. The nurse case manager will work with you, your
Physician and other health care providers to design a treatment plan to best meet your health care needs. In order to
implement the plan, you, your Physician and Blue Cross must agree to the terms of the plan. The program is
voluntary to you and your Physician; you are not required to work with a Blue Cross case management nurse.
Benefits provided are subject to all provisions and limitations of the Plan. For additional information on individual
case management, call the Blue Cross Health Management division at (205) 733-7067 or 1-800-821-7231.
CARE MANAGEMENT PROGRAM
If you suffer from certain long-term, chronic diseases or conditions, you may qualify to participate in the Blue Cross
Care Management Program. Care Management is designed for individuals whose long-term medical needs require
disciplined compliance with a variety of medical and lifestyle requirements. If the manager of the Care
Management Program determines from your claims data that you are a good candidate for Care Management, the
manager will contact you and ask if you would like to participate in the program. Participation is completely
voluntary. If you would like to obtain more information about the Care Management Program, call Blue Cross and
Blue Shield Customer Service at (251) 343-4001 or 1-800-253-9305.
PERSONAL WELLNESS PROFILE
This program allows Members to assess the condition of their health. Members age 14 and over may complete a
Personal Wellness Profile, which provides a health analysis report. It informs Members about their individual
potential health risk areas and provides practical suggestions to help Members make changes in their lifestyles to
improve overall health. This service is provided at no charge. To access this service, go to the website
www.bcbsal.com and select “Personal Wellness Profile” from the menu choices. The website also provides
information on a number of health related topics.
CUSTOMERACCESS
“CustomerAccess” is a service that allows Members to review specific information related to their health claims,
order ID cards, claim forms and other materials, verify student eligibility and access “For Your Health,” a website
with the latest health information, including individualized information via the Personal Wellness Profile. To access
this service go to the website www.bcbsal.com and select CustomerAccess.
18
HEALTH PLAN COVERED SERVICES
COVERED SERVICES
8. Physical therapy, radiation therapy and
chemotherapy when required to be provided on
an inpatient basis.
The Plan covers the following services and supplies
provided to a Member subject to all provisions,
limitations and exclusions stated in this Member
Handbook.
9. All drugs and medicines used in the Hospital
and administered by a Hospital employee.
These Covered Services apply to Blue Cross and
Blue Shield Providers, including USA Health
System Providers.
10. Blood transfusions administered by a Hospital
employee, including supplies and use of
equipment.
It is important that you read the Member Handbook
so you will understand the benefits available to you
and the restrictions that apply to some Covered
Services. Some Covered Services are available only
when rendered by a Blue Cross and Blue Shield
Provider and some Covered Services are limited by a
Calendar Year or Lifetime Maximum Benefit. It is
important that you understand the lowest Copay
amounts are available only when the Covered
Service is rendered by a USA Health System
Provider.
OUTPATIENT HOSPITAL COVERED SERVICES
The following are Covered Services for outpatient
treatment subject to all provisions, limitations and
exclusions of the Plan:
1. Charges by the Hospital for treatment of an
Injury or Medical Emergency.
2. Charges by the Hospital for surgery in the outpatient department.
3. Hospital charges for hemodialysis and peritoneal
dialysis for end-stage renal disease when the
facility is approved for participation in the
Medicare program.
INPATIENT HOSPITAL COVERED SERVICES
The Plan covers the following services and supplies
provided to a Member while a patient in a Hospital:
4. Services for removal of impacted, unerupted
teeth or other dental processes when full surgical
and support services are determined Medically
Necessary due to the medical condition of the
Member.
1. Bed, board and general nursing care in a semiprivate room. A private room charge in excess
of the semi-private rate is the responsibility of
the Member.
5. Hospital charges for pre-operative laboratory
tests, X-rays, and other diagnostic related tests
ordered by the attending Physician and
conducted within seven days prior to surgery.
2. Use of operating, delivery, recovery and
treatment rooms, and the equipment in them.
3. Intensive care and other special care units (such
as cardiac care and pediatric intensive care),
including special equipment and concentrated
nursing services provided by Hospital
employees. Benefits will not be provided for
bed and board in another room while you are in
a special care unit.
6. Charges by an ambulatory surgical facility.
7. IV therapy, chemotherapy and radiation therapy.
PHYSICIAN COVERED SERVICES
4. Anesthesia including supplies, use of equipment
and administration by a Hospital employee.
The following are Covered Services subject to all
provisions, limitations and exclusions of the Plan:
5. Casts and splints, surgical dressings, treatment
and dressing trays.
1. Medical care and treatment including office
visits and second surgical opinions, inpatient
Hospital visits, and outpatient treatment of an
Injury or Medical Emergency.
6. Diagnostic tests including, but not limited to,
laboratory exams, x-rays, metabolism tests,
cardiographic exams, and encephalograms.
2. Surgical operations and procedures, including
the active services of an assisting surgeon when
Medically Necessary.
7. Oxygen and its administration.
19
3. Anesthetics and their administration, including
supplies and use of equipment, when rendered
by a Physician (other than the operating surgeon
or obstetrician).
The following are not Covered Services:
1. Fertility testing and treatment, and assisted
reproductive technology, including but not
limited to tubal transfer, in vitro fertilization,
gamete intrafallopian transfer or zygote
intrafallopian transfer and pro-nuclear stage
tubal transfer.
4. Diagnostic lab, x-ray and pathology services in
the Physician’s office (if lab results are
generated in the outpatient department of a
Hospital or an independent lab, the charges may
be subject to a Copay according to the
provisions of the Plan).
2. Genetic testing.
5. Services of a radiologist or pathologist.
3. Expenses related to the Pregnancy of any
Eligible Dependent other than the legal spouse
of the Eligible Employee.
6. Chiropractic services and related expenses, up to
the $1,000 Calendar Year Maximum Benefit.
4. Ultrasound or related tests performed primarily
to determine the sex of the unborn child.
7. Inpatient consultation by a specialist Physician
for a medical, surgical or maternity condition,
limited to one for each Hospital stay.
5. Ambulance service to a Hospital for delivery
when provided primarily for the comfort and
convenience of the Member and not certified by
a Physician as Medically Necessary.
SERVICES RELATING TO PREGNANCY AND
DELIVERY
OTHER COVERED SERVICES
The following are also Covered Services subject to
all Plan provisions, limitations and exclusions:
The following information is provided to assist
Members in understanding benefits related to
Pregnancy and delivery.
1. Allergy testing and treatment, including serum.
The following are Covered Services under the Plan:
2. Ambulance service to the nearest Hospital able
to provide necessary care, and transportation to a
Hospital for specialty care when ordered by a
Physician.
1. The Baby Yourself pre-natal wellness program
for high-risk Pregnancy early intervention.
2. Obstetrical care, including Physician services,
during Pregnancy and childbirth.
3. Blood and blood plasma; visualizing dyes and
other injections into the circulatory system for
diagnosis and treatment.
3. Services of a Certified Nurse Midwife.
4. Inpatient Hospital expenses for delivery. If care
is rendered for multiple births during the same
Pregnancy, the Plan will pay the largest Allowed
Amount regardless of the number of babies
delivered or method(s) of delivery.
4. Cardiac rehabilitation, when ordered by a
Physician following cardiac surgery or as a
preventive measure for cardiac-related diagnoses
including, but not limited to, stable angina,
coronary artery bypass graft (CABG),
myocardial infarction, hypertension, and
coronary artery disease. Cardiac rehabilitation
as a treatment for obesity is not a Covered
Service. Cardiac rehabilitation is limited to a
Maximum Benefit of 36 treatment sessions per
cardiac episode.
5. Inpatient Hospital expenses related to ordinary
nursery care and diaper service for a newborn,
when the mother is covered under the Plan.
6. Physician inpatient visits for routine newborn
care.
7. In most cases, a well baby’s charges will be
listed under the mother’s charges for an inpatient
hospitalization. In the case of a sick baby, when
the baby incurs charges under its own name,
charges will be covered under inpatient Hospital
benefits, subject to any applicable inpatient
Hospital Deductible and daily Copay.
5. Certified Registered Nurse Anesthetist (CRNA),
only when billed by the Hospital or supervising
Physician. The Plan will pay the Hospital or
supervising Physician for services.
8. Circumcision of a newborn baby.
20
OTHER COVERED SERVICES
CONTINUED
6. Colorectal cancer screening, as provided under
the Plan’s preventive care benefits. If additional
colorectal cancer screenings are performed in
connection with the diagnosis or treatment of a
medical condition, and if the Physician files the
claim with this information, the screening will
be a Covered Service paid as a diagnostic
procedure. If additional colorectal screenings
are performed because you are at high risk of
developing colon cancer or you have a family
history of colon cancer, and if the Physician files
the claim with this information, the screening
will be a Covered Service paid as a diagnostic
procedure.
Diagnostic tests performed in the outpatient
department of a USA Health System Provider
Hospital or outpatient center are covered at
100%.
Diagnostic tests performed in the
outpatient department of a non-USA Hospital or
outpatient center are covered at 100% after a $5
Copay is applied to each test.
11. Diagnostic imaging, including but not limited
to x-rays, CT Scans, MRIs, MRAs, CTAs and
Petscans. How benefits are paid for diagnostic xrays depends on where the test is performed, and
where the results are generated. A diagnostic
image performed in a Physician’s office is
covered at 100%. A diagnostic image performed
in the outpatient department of a USA Health
System Provider Hospital or outpatient center is
covered at 100%; otherwise, the diagnostic
image is covered at 100% after a $50 Copay.
7. Contact lenses, one pair, one pair of eyeglasses
or one pair of each, if Medically Necessary to
replace the human lens function as a result of
intraocular surgery or ocular injury or defect.
8. Contraceptives, including oral and injectable
contraceptives, diaphragms, IUDs and other
FDA-approved contraceptives, and required
Physician services associated with contraceptive
management. Oral contraceptives are covered
under the Prescription Drug Card benefit.
12. Durable Medical Equipment, such as
wheelchairs and hospital beds, prescribed by a
Physician for use in a Member’s home. Refer to
the section titled Home Health Care – Benefit
Limitation for additional information.
13. Elective abortion, only when ordered by a
Physician to protect the mother’s physical life,
or the Pregnancy resulted from a criminal act, or
the mother has AIDS or is a drug addict.
9. Diabetic supplies, are provided under the
Prescription Drug Card benefit only. Diabetic
testing supplies including blood glucose test
strips, lancets, and meters are available only
through the pharmacy benefit, not subject to any
copay or deductible. Only supplies submitted
electronically by a Participating Pharmacy are
covered.
There are no diabetic supplies
provided under the Home Health Care Benefit.
Injectable and oral diabetic medications will
require a copay and are subject to the deductible.
14. Elective sterilization, including vasectomy
when performed in a Physician’s office, or tubal
ligation when performed on an outpatient basis
or with delivery as an inpatient.
15. Eye examinations for routine purposes, limited
to a per-Member Maximum Benefit of once each
Calendar Year.
16. Extended Care Facility, limited to a Maximum
Benefit of 60 days per Calendar Year. Refer to
the section titled Extended Care Facility –
Benefit Limitation for additional information.
10. Diagnostic tests, including but not limited to
laboratory exams, metabolism tests, and
pathology. How benefits are paid for diagnostic
tests depends on where the test is performed, and
where the results are generated. Diagnostic tests
performed in the office of a USA Health System
Provider Physician are covered at 100%.
Diagnostic tests performed in the office of a
Physician other than a USA Health System
Provider are covered at 100% when the results
are generated by the Physician’s office; when
the results are generated by the outpatient
department of a Hospital or an independent lab,
a $5 Copay applies to each test, after which the
test is covered at 100%.
17. Hemodialysis and peritoneal dialysis treatment
for end-stage renal disease.
18. Home Care Medical Supplies ordered by a
Blue Cross and Blue Shield Provider Physician
for home use and required due to chronic Illness.
Refer to the section titled Home Health Care –
Benefit Limitation for additional information.
21
OTHER COVERED SERVICES
CONTINUED
19. Home Health Care including intermittent services
of a registered nurse or licensed practical nurse.
Refer to the section titled Home Health Care –
Benefit Limitation for additional information.
Only one surgical procedure for morbid obesity
will be a Covered Service during a Member’s
lifetime, regardless of whether the first such
surgery was covered by this Plan.
20. Hospice Care, provided to Terminally Ill Members
and limited to a Lifetime Maximum Benefit of 180
days. Refer to the section titled Hospice Care –
Benefit Limitation for additional information.
26. Oral surgery and restorative dentistry when
necessary for the prompt, initial treatment of
Injury to sound natural teeth, caused by a force
outside the oral cavity and body. Coverage for
initial treatment includes necessary services that
are provided within 12 months of the date of the
Injury, including the first dental prosthesis such
as a crown or bridge if necessary. Only the
Physician’s charges for this treatment are
Covered Services under the Health Plan. Refer
to the Dental Plan section of this Member
Handbook for information on services covered
under the Dental Plan.
21. Immunizations, including only immunizations
to prevent diphtheria, tetanus, pertussis, polio,
rubella, mumps, measles, Hib (meningitis,
epiglottitis and joint infections), meningococcal
disease, hepatitis B and chicken pox for any age,
and to prevent invasive pneumococcal disease in
children during the first two years of life, or
influenza in children during the sixth through the
23rd months of life. Immunizations required
solely for the purpose of foreign travel are not
covered.
27. Organ and tissue transplants, limited to
specific services, and limited to skin, cornea,
kidney, liver, pancreas, small bowel, heart,
heart-valve, heart/lung, lung and bone marrow
including stem cells and autologous bone marrow.
Refer to the section titled Organ and Tissue
Transplants – Benefit Limitation for additional
information.
22. Licensed Professional Counselor (LPC) or
Licensed Clinical Social Worker (LCSW) under
the benefits provided for Mental Health and
Substance Abuse Treatment, limited to a
Calendar Year Maximum Benefit of 40 visits.
23. Mammograms, as provided under preventive
care services. If additional mammograms are
performed in connection with the diagnosis or
treatment of a medical condition, and if the
Physician files the claim with this information,
the mammogram will be a Covered Service paid
as a diagnostic procedure.
If additional
mammograms are performed because you are at
high risk of developing breast cancer or you
have a family history of breast cancer, and if the
Physician files the claim with this information,
the mammogram will be a Covered Service paid
as a diagnostic procedure.
28. Orthotic devices placed inside or attached to a
shoe to support, realign or change gait function,
or to treat a varus or valgus deformity, calcaneal
apophysitis, plantar fascities or calcaneal
periostitis, including only gait plates, heel
stabilizers, Whitman plates, Roberts plates,
biomedical functional orthotics and Schaefer
orthotics, and molded shoes to treat deformed or
severely maligned or neuropathic sensitive feet,
such as in diabetics. Orthotic devices are
covered under Durable Medical Equipment
benefits, limited to a Maximum Benefit of two
pair each 12 consecutive month period.
24. Mental Health Treatment and Substance
Abuse Treatment. Refer to the section titled
Mental Health Treatment and Substance Abuse
Treatment – Benefit Limitation for additional
information.
29. Physical therapy or occupational therapy by a
licensed therapist, who is not related to the
Member, limited to a Maximum Benefit of 60
sessions each per Calendar Year.
30. Physician Assistant (PA) , Nurse Practitioner
(NP), Certified Surgical Technician (CST) or
assistant surgical nurse services.
25. Morbid obesity surgery, only within the Claims
Administrator’s approved Network of Physicians
for bariatric surgery and gastric restrictive
procedures, when in compliance with the Claims
Administrator’s guidelines, and when there is a
documented history of unsuccessful attempts to
reduce weight by more conservative measures.
22
OTHER COVERED SERVICES
CONTINUED
31. Prescription drugs as provided under the
Prescription Drug Card benefit, subject to the $50
Calendar Year Prescription Deductible, limited to
a maximum of three Deductibles per family. The
Member pays the required Copay or the amount
of the drug if it is less than the Copay. Drugs will
be dispensed in a maximum of a 34-day supply
for each drug or refill. Maintenance drugs may
be dispensed in the greater of a 90-day supply or
100 unit doses. In the case of maintenance drugs,
the applicable Copay applies to each 30-day
supply. Refills are allowed only after 60% of the
previous prescription has been used (for example,
18 days into a 30-day supply). There are no
benefits for drugs purchased from a nonparticipating pharmacy in the state of Alabama.
Prescription drugs purchased from a nonparticipating pharmacy out of state or out of the
country will be processed at the participating
pharmacy allowance plus the applicable Copay.
The Member will be responsible for any cost over
the participating pharmacy allowance plus the
applicable copayment. The Member must file a
claim including the pharmacy receipts.
36. Reconstructive Surgery when determined to be
Medically Necessary and not for Cosmetic
purposes or related to complications of Cosmetic
services or Cosmetic surgery.
37. Sleep apnea, including studies for diagnosis and
treatment of infant apnea or Obstructive Sleep
Apnea Syndrome (OSAS), when provided in a
sleep disorder center accredited by the American
Sleep Disorders Association.
38. Speech therapy and audiology services,
required due to an Illness or Injury or to correct
speech deficiencies including but not limited to
developmental articulation disorders and
stuttering. Speech therapy includes treatment of
speech, language, voice, communication and
auditory processing disorders, including medical
diagnostic evaluation, when provided by a
licensed therapist who is not related to the
Member, limited to a Calendar Year Maximum
Benefit of 60 treatment sessions.
39. Temporomandibular Joint Disorder (TMJ),
Phase I treatment, as approved by the American
Academy of Craniomandibular Disorders, and
surgical services involving the mandible and
maxilla when TMJ is diagnosed. Phase I is
diagnosis and initial treatment including
examination, x-rays and study casts, TMJ joint
repositioning appliances, removable or fixed
(limited to one every three years), and six office
visits every three years.
32. Physical examinations, but only as provided
under the Plan’s preventive care benefits.
33. Prosthetic appliances, such as artificial limbs
and eyes, required as a result of Injury or Illness
incurred while covered under the Plan, and
replacements as determined to be Medically
Necessary, covered as Durable Medical
Equipment under the Home Health Care benefit.
34. Radiologist or pathologist services, when
ordered by a Physician, including radiation
therapy and chemotherapy.
35. Reconstructive surgery following mastectomy
for breast cancer including reconstructive
surgery of the breast on which the mastectomy
was performed, and of the other breast to
produce a symmetrical appearance; prosthesis
and coverage of physical complications resulting
from all stages of the mastectomy, including
lymphedemas. Coverage of prosthesis includes
initial placement of the prosthesis and
replacements as determined to be Medically
Necessary; and the brassiere required to hold the
prosthesis, limited to a Maximum Benefit of
four (4) each Calendar Year.
23
HEALTH PLAN BENEFIT LIMITATIONS
PRE-EXISTING CONDITIONS EXCLUSION
the period of time the Employee has been employed
in a benefits eligible position.
The USA Health Plan has exercised its right to be
exempt from the Health Insurance Portability and
Accountability Act (HIPAA). New Employees and
their Eligible Dependents, and any Employees or
Eligible Dependents enrolling during the Open
Enrollment Period, must be covered under the USA
Health Plan for 270 days before any benefits are
available for Pre-Existing Conditions.
NEWBORN AND ADOPTED CHILDREN: The PreExisting Condition Exclusion does not apply to a
newborn child of the Eligible Employee when the
newborn child is enrolled within 30 days of birth.
The Pre-Existing Condition Exclusion does not
apply to a newborn child or an adopted child of the
Eligible Employee, provided Application is made
within 30 days of the child’s birth, adoption or
placement for adoption.
Certificates of prior coverage from your previous
insurance plan will not be accepted to reduce this
waiting period. You may wish to give serious
consideration to continuing the COBRA privilege
granted under your previous employer’s health
plan.
LIFETIME MAXIMUM BENEFIT LIMITATION
There is a $1,000,000 Maximum Benefit for all
Covered Services for any one Member during his or
her lifetime.
The Lifetime Maximum Benefit
applies even if coverage is terminated and reinstated
or if the Member is covered at one time as an
Eligible Dependent and at another time as the
Employee. Included in that $1,000,000 Lifetime
Maximum Benefit are the following Maximum
Benefit Limitations:
Pre-Existing Conditions include pregnancy or any
disease, disorder or ailment, congenital or otherwise,
which existed on or before the Effective Date of
coverage, whether or not it was manifested or known
in any way, or any condition diagnosed or treated in
the 12 months before the Effective Date of coverage.
The determination as to whether or not a medical
condition is pre-existing shall be made by the
Claims Administrator.
1. Inpatient and outpatient Substance
Treatment is limited to $25,000.
Abuse
After completing the 270-day waiting period,
benefits will be paid for any covered medical
condition whether or not it existed prior to the
Effective Date of coverage.
2. Inpatient Hospital services and Inpatient
Physician services for Mental Health and
Substance Abuse Treatment are limited to a
maximum of 60 days.
The Pre-Existing Conditions Exclusion applies to
each Member, individually.
The Pre-Existing
Condition Exclusion applies to initial enrollment and
to Open Enrollment Periods. This Pre-Existing
Condition provision also applies to an Employee
applying for reinstatement of coverage under the
Plan, except for an Employee returning to
employment from an authorized leave of absence
under the Family and Medical Leave Act or
USERRA.
3. Orthodontia and periodontia services required
after orthognathic surgery are limited to $4,000.
4. Surgery for the treatment of morbid obesity is
limited to one procedure.
5. Charges of a licensed Hospice facility are
limited to a maximum of 180 days.
CALENDAR YEAR MAXIMUM BENEFIT
LIMITATION
SPECIAL ENROLLMENT PERIOD: A Special
Enrollment Period is available for enrollment by
Employees and/or their Eligible Dependents within
30 days of a Change-In-Status Event, as explained in
this USA Health Plan Member Handbook.
Calendar Year Maximum Benefit amounts apply
even if coverage is terminated and reinstated. The
Maximum Benefit amount for each Member per
Calendar Year is as follows:
1. Home Health Care including intermittent skilled
nursing care, Durable Medical Equipment and
Home Care Medical Supplies is limited to
$30,000.
Employees and/or their Eligible Dependents who
experience a Change-In-Status-Event may have the
Pre-Existing Conditions Exclusion waiting period
waived in whole or in part, by receiving credit for
24
2. Inpatient Hospital services and Inpatient
Physician services for Mental Health and
Substance Abuse Treatment are limited to 30
days.
Outpatient treatment is also a Covered Service, paid
at 80% of the Allowed Amount, subject to the $250
Calendar Year Deductible and limited to a Calendar
Year Maximum Benefit of 40 visits.
3. Outpatient Physician services for Mental Health
and Substance Abuse Treatment are limited to
40 visits.
ORGAN AND TISSUE TRANSPLANTS –
BENEFIT LIMITATION
Benefits are available for services and expenses in
connection with some transplants of organs and
tissues. These include only transplants of skin,
cornea, kidney, liver, pancreas, heart, heart-valve,
heart/lung, lung, small bowel, and bone marrow,
including stem cell and autologous bone marrow.
4. Chiropractic services are limited to $1,000.
5. Physical therapy, occupational therapy and
speech therapy, when a Covered Service, are
limited to 60 treatment sessions each.
6. Preventive care benefits have age and Calendar
Year Maximum Benefit Limitations. Refer to
“Preventive Care Services” under the section
titled Health Plan Benefits for Covered Services
for additional information.
Services and expenses are covered only when
performed in a designated network transplant facility
or at a facility approved in writing by the Claims
Administrator in advance of any procedure related to
the organ transplant.
7. Placement of approved orthotic devices are
limited to a Maximum Benefit of two pair each
12 consecutive month period.
Medical and Hospital services and expenses for
obtaining and transporting organs and tissues
(procurement costs) are also covered. Also covered
are immunosuppressant drugs. The replacement of
natural organs with artificial or mechanical devices
is not covered. Also excluded from coverage are all
costs associated with screening and testing of
potential donors.
8. Coverage of prosthesis following a mastectomy
includes the brassiere required to hold the
prosthesis, limited to four per Calendar Year.
9. Benefits for an Extended Care Facility are
limited to 60 days.
10. Cardiac rehabilitation is limited to a Maximum
Benefit of 36 treatment sessions per cardiac
episode.
If the recipient is covered by this Plan and the donor
is not, benefits are provided to the recipient but not
to the donor. If the donor is covered by this Plan
and the recipient is not, benefits are provided to the
donor but not to the recipient. If both the donor and
recipient are covered by this Plan, benefits will be
provided for both.
MENTAL HEALTH TREATMENT AND SUBSTANCE
ABUSE TREATMENT– BENEFIT LIMITATION
Covered Services include inpatient and outpatient
Mental Health and Substance Abuse Treatment.
Services must be rendered or prescribed by a
psychiatrist, psychologist, Licensed Professional
Counselor (LPC) or Licensed Clinical Social Worker
(LCSW).
Expenses are subject to the Allowed Amount and
other Plan provisions and limitations. The Plan
reserves the right to set the maximum expense it
feels to be reasonable for the transplant procedure
and necessary for the maintenance of good health of
the Member.
Covered Services related to inpatient and outpatient
Substance Abuse Treatment are limited to a
combined Lifetime Maximum Benefit of $25,000.
EXTENDED CARE FACILITY –
BENEFIT LIMITATION
Inpatient Hospital and Physician treatment in a
Hospital or residential Substance Abuse Treatment
facility is a Covered Service, paid at 80% of the
Allowed Amount subject to the $250 Calendar Year
Deductible, and limited to a Calendar Year
Maximum Benefit of 30 days and a Lifetime
Maximum Benefit of 60 days.
Benefits for an Extended Care Facility are limited to
a Calendar Year Maximum Benefit of 60 days.
Benefits are available only when the confinement in
an Extended Care Facility begins within 14 days of
the last day of an inpatient Hospital confinement.
An Extended Care Facility is a skilled nursing
facility that is Medicare-approved to provide nonacute care for patients requiring 24-hour nursing
Pre-Certification of inpatient Hospital admissions is
required.
25
3. Home Care Medical Supplies – medical supplies
ordered by a Blue Cross and Blue Shield
Provider Physician for home use and required
due to chronic Illness, limited to only: oxygen,
IV therapy solutions, crutches, splints, casts,
trusses and braces, specialty dressings for open
wounds, syringes and needles, blood glucose
strips, lancets and glucose monitors, tubing kits
for insulin pumps, catheters, colostomy bags,
compression stockings and medical supplies
required in conjunction with an authorized
Home Health Care visit.
services. An Extended Care Facility (1) is engaged
in providing skilled care under the supervision of
Physicians and registered nurses; (2) maintains
clinical records on all patients; (3) provides 24-hour
nursing services; and (4) provides appropriate
procedures for dispensing and administering drugs
and is duly licensed. Facilities for custodial,
domiciliary care, Mental Health or Substance Abuse
treatment are not covered.
HOME HEALTH CARE – BENEFIT LIMITATION
All benefits for Home Health Care are limited to a
Maximum Benefit of $30,000 per Member per
Calendar Year. Benefits for Home Health Care are
provided only when a Blue Cross and Blue Shield
Provider is used.
HOSPICE CARE – BENEFIT LIMITATION
Hospice Care is provided only to Terminally Ill
Members, and includes Physician home visits, home
physical therapy and medical social services, or
inpatient Hospice Care when there are no suitable
caregivers available to provide care at home for a
Terminally Ill Member, or to provide temporary
relief for a caregiver. Hospice Care is limited to a
Lifetime Maximum Benefit of 180 days and must be
furnished by a Blue Cross and Blue Shield Provider.
Refer to the Definitions section for additional
information.
All services and expenses must be submitted to the
Claims Administrator for Pre-Certification. No
Home Health Care service or expense is a Covered
Service until approval is obtained. Home Health
Care Covered Services include:
1. Skilled Nursing Care – intermittent services
(less than an eight-hour shift) provided by a
registered nurse, licensed practical nurse or
home health aide who is not related to the
Member nor regularly resides in the Member’s
household. The services must be ordered by a
Physician and performed outside of a Hospital or
any other acute care facility setting by a Blue
Cross and Blue Shield Provider. No benefits are
provided for Custodial Care.
CLAIMS FILING DEADLINE
In most cases, a Blue Cross and Blue Shield
Provider will file a medical claim. You may be
required to file a claim for services received Out-ofNetwork.
You should file a claim for benefits with the Claims
Administrator within 90 days of incurring a medical
expense. Failure to file a claim for benefits within
12 months of the date of service or date the
expense was incurred will result in denial of
benefits. A claim is considered filed when all
information necessary for processing the claim has
been received by the Claims Administrator.
2. Durable Medical Equipment – equipment, such
as wheelchairs, hospital beds, external insulin
infusion pumps, and initial placement and
replacement of prosthetic, orthotic and
orthopedic devices, certified as Medically
Necessary to treat an Illness or Injury, or to
improve the functions of a malformed body
member. Rental of Durable Medical Equipment
is covered provided the aggregate rental charges
do not exceed a reasonable purchase price;
purchase of may be approved if purchase is less
costly than rental. Refer to the Definitions
section for additional information.
NO LIMITATIONS ON LENGTH OF STAY
The USA Health Plan does not restrict benefits to an
established length of stay for any condition except
Mental Health and Substance Abuse Treatment.
Hospital admissions are based solely on Medical
Necessity, in coordination with the attending
Physician.
26
BENEFIT EXCLUSIONS
PLEASE READ THIS SECTION CAREFULLY. The
following conditions, services and expenses are not
covered under any part of the Plan.
9. Expenses exceed the Maximum Benefit
Limitation per Calendar Year, Lifetime or under
any other benefit limitation provision.
Because it is impossible to create an all-inclusive
list, the University of South Alabama reserves the
right to review and exclude any services or expenses
for conditions or procedures as necessary to avoid
adverse selection and to protect the integrity of the
Plan.
10. Covered Services received before the Member’s
Effective Date of coverage.
11. Covered Services received after the Member’s
date of termination of coverage.
12. Covered Services received for treatment of a
Pre-Existing Condition during the 270-day
waiting period when such services are excluded
from coverage.
EXCLUSIONS BY PROVISION
Services and expenses, even if Covered Services, are
excluded from coverage under the Plan due to the
following terms, conditions and Plan provisions:
13. Covered Services provided after your failure to
provide verification of dependent status within
30 days of a request from the Human Resources
Department or the Claims Administrator, and the
individual’s coverage under this Plan has been
terminated, retroactive to the earliest date the
Claims Administrator was able to determine the
individual ceased to be an Eligible Dependent.
1. The service or expense is not specifically listed
as a Covered Service, or is a complication
arising from a condition or service that is not
covered by the Plan.
2. The service, expense or treatment was not
determined by the Claims Administrator to be
Medically Necessary, including when services
are provided for the personal comfort or
convenience of the Member, or the Member’s
caregivers.
14. For Eligible Dependents, Covered Services
covered in whole or part by workers’
compensation or employers’ liability laws,
whether or not you file for such benefits under
applicable law, or if liability is enforced against
or assumed by an employer.
3. The service or expense is received Out-ofNetwork and is a Covered Service only when
received from or authorized by a Blue Cross and
Blue Shield Provider.
15. Injury or Illness resulting from war, declared or
undeclared, or Uniformed Services duty.
4. The service or expense is received without PreCertification and is a Covered Service only
when Pre-Certified.
16. Injury or Illness incurred in connection with the
commission of a crime or participation in a riot
or civil commotion, or while the Member was
confined in a penal institution.
5. A claim for services and expenses has not been
received by the Claims Administrator within 12
months of the date of service or the date the
expense was incurred.
17. Treatment was received in a federal Hospital or
treatment facility owned or operated by the
United States government or one of its agencies,
except as provided by federal law.
6. The claim for services or expenses was not
properly submitted according to the instructions
provided in the section titled How to File A
Claim for Benefits in this Member Handbook.
18. Services or expenses of any kind to which a
Member is, or upon application would be,
entitled to coverage under Medicare, whether or
not application has been made, except as
provided by federal law.
7. The service, expense or treatment was not
required, referred, prescribed or arranged by a
Physician.
19. Services for which the Member is under no legal
obligation to pay, or a service for which no
charge would have been made if the Member
had not had health benefits coverage.
8. Charges for Covered Services in excess of the
Allowed Amount.
27
HEALTH PLAN BENEFIT EXCLUSIONS
The following conditions, situations, expenses and
services are not Covered Services under the Health
Plan, whether or not recommended by a Physician
and certified as Medically Necessary:
8. Drugs that can be purchased without a written
prescription (over the counter) and kits for home
testing, including but not limited to HIV,
Pregnancy or allergies, except for diabetic
supplies, which may be purchased over the
counter and are covered under the Plan.
1. Acupuncture or acupressure treatment.
2. Appliances such as air-purification units, air
conditioners, allergy-free bedding, humidifiers,
heating pads, environmental control units, hot
tubs, exercise equipment, orthopedic mattresses,
vacuum cleaners, swimming pools, electromagnetic bone stimulators, elevators or stair
lifts, wheelchair lifts for automobiles, motorized
transportation devices, non-hospital adjustable
beds, safety rails, blood pressure or other
monitoring equipment and any equipment that
does not meet the definition of Durable Medical
Equipment or Home Care Medical Supplies.
9. Drugs for Cosmetic or weight loss purposes,
nutritional or dietary supplements, including
charges for megavitamin therapy.
10. Drugs not used for the specific treatment of
Illness or Injury, prescriptions related to an
otherwise non-Covered procedure, uses of drugs
for purposes not specifically approved by the
FDA (off-label), or drugs not approved by the
Claims Administrator.
11. Elective abortion, except to protect the physical
life of the mother, or the Pregnancy was a result
of a criminal act or the mother has AIDS or is a
drug addict.
3. Assisted reproductive technology, including
but not limited to tubal transfer, in vitro
fertilization, gamete intrafallopian transfer or
zygote intrafallopian transfer and pro-nuclear
stage tubal transfer.
12. Emergency room services or use of an
emergency room Physician for medical care
which is not required as a result of a Medical
Emergency.
4. Bed and board for an empty Hospital bed when
the patient is confined to a special care unit.
13. Experimental or Investigative procedures,
drugs, treatments, equipment or supplies. Refer
to the Definitions section for additional
information.
5. Cosmetic treatments, including Cosmetic
surgery or drugs for Cosmetic purposes, and any
complications or subsequent surgery related in
any way to Cosmetic services or surgery.
14. Exercise or physical fitness programs, weight
reduction, weight control or dietary control
procedures, or drugs for weight loss purposes,
nutritional or dietary supplements, except for
surgery to correct morbid obesity, when
determined by the Claims Administrator to be
Medically Necessary, based on criteria
established by the Claims Administrator, to
protect the life of the Member.
6. Custodial Care, sanitarium care, convalescent
care or rest cures, except as provided under the
Extended Care Facility – Benefit Limitation.
7. Dental treatment, or any services related to
conditions of the teeth or supporting structures,
including periodontal disease or gum disease, or
caused through the activities of daily living such
as biting, chewing, clenching and grinding.
Physician’s charges for oral surgery and
restorative dentistry are a Covered Service under
the Health Plan when necessary for the prompt,
initial treatment of Injury to sound natural teeth,
caused by a force outside the oral cavity, and
treatment is provided within 12 months of the
date of Injury. Outpatient Hospital services for
the removal of impacted, unerupted wisdom teeth
are covered under the Health Plan only when
Medically Necessary due to the medical condition
of the patient. Refer to the section titled Dental
Plan for information on treatment considered to
be a Covered Service under the Dental Plan.
15. Eyeglasses or contact lenses, except for initial
placement of contact lenses or eyeglasses if
Medically Necessary to replace the human lens
function as a result of intraocular surgery or
ocular injury or defect.
28
16. Foot treatments, including non-surgical
treatment of feet, orthotic devices designed to
simply support the arch or pad of the foot and
that are not functioning to change a pathological
gait or stance problem, orthopedic shoes or
prescription shoes (except molded shoes), and
routine foot care such as removal of corns or
calluses or the trimming of nails, except
trimming of mycotic nails.
EXCLUSION OF SERVICES
CONTINUED
17. Genetic testing or counseling, or other analysis
to identify a variant genetic code, to detect a
genetic disease or to predict the likelihood of
developing a genetic disease.
31. Private room charges while hospitalized, except
when required by a Physician due to Medical
Necessity.
32. Psychological testing or counseling, educational
or vocational testing or training, testing for or
treatment of learning disabilities or behavioral
problems.
18. Hearing aids or the implantation of prosthetic
devices to improve hearing, including but not
limited to devices used in the treatment of
tinnitus.
33. Reversal of elective sterilization.
19. Immunizations, except as provided under the
preventive care benefits of the Plan.
34. Self-care or self-help therapy or training,
including but not limited to hypnosis, stress
management,
bio-feedback
or
behavior
modification therapy.
20. Infertility studies, tests to determine fertility or
the use of fertility drugs.
21. Learning disability therapy, testing or
treatment including that for perceptual disorders
or behavioral disorders.
35. Sexual dysfunction or inadequacy not related to
organic disease, including progesterone or
testosterone or their derivatives, Viagra™ or any
other drugs prescribed to treat a sexual
dysfunction or inadequacy that is not directly
related to organic disease.
22. Mental Health and Substance Abuse
Treatment except as specified in the section
titled Mental Health and Substance Abuse
Treatment – Benefit Limitation.
36. Smoking cessation treatments, including drugs
prescribed for the primary purpose of assisting
in smoking cessation and nicotine replacements
including but not limited to patches or gum.
23. Nursery care and diaper service in the Hospital
for a newborn dependent if the mother does not
have coverage under the Plan.
24. Occupational therapy, recreational therapy or
educational therapy. Occupational therapy is
covered only when Medically Necessary due to
Illness or Injury as part of a regimen of physical
therapy.
37. Surgical sex transformations, or treatment for
complications resulting from surgical sex
transformations.
38. Travel and lodging for any physical condition,
whether or not required by a Physician.
25. Organ or tissue transplants or related services
not specifically listed in the section titled Organ
and Tissue Transplant – Benefit Limitation.
39. Ultrasound when performed primarily
determine the sex of an unborn child.
26. Physical examinations required for insurance
policies, employment screening, recreational
activities or government licensing, except when
such purposes are incidental to the routine
preventive care benefits provided.
40. Vision therapy, visual training, or orthoptics, or
any eye surgery, including but not limited to
refractive keratoplasty in all forms when the
primary purpose is to correct myopia
(nearsightedness), hyperopia (farsightedness) or
astigmatism (blurring).
27. Pre-operative lab tests not conducted within
seven days prior to surgery.
to
41. Weight reduction, weight control or dietary
control treatment, or drugs for weight loss
purposes, nutritional or dietary supplements.
The only exception is surgery to correct morbid
obesity, within the Claims Administrator’s
approved Network of Physicians for bariatric
surgery and gastric restrictive procedures, when
determined to be Medically Necessary and
performed according to the guidelines of the
Claims Administrator and limitations of the
Plan.
28. Pregnancy services, including Complications of
Pregnancy, and postpartum period of any
Eligible Dependent other than the legal spouse
of the Eligible Employee.
29. Prescription drugs purchased at a nonparticipating pharmacy in the state of Alabama.
30. Private duty nursing care, except as provided
for in the section titled Home Health Care –
Benefit Limitation.
29
DENTAL PLAN BENEFITS
ABOUT THE DENTAL PLAN
NON-PREFERRED DENTIST BENEFITS
If you or your Eligible Dependent, while covered
under the Plan, incurs an expense for Dental Plan
Covered Services, the Plan will pay for that expense
as described below in this Member Handbook.
Some limitations and exclusions apply.
Benefits are reduced if you receive services from a
Non-Preferred Dentist who does not participate in
the Preferred Dentist program. If you choose to use
a Non-Preferred Dentist, you must be aware of the
following:
1. It will be your responsibility to arrange for PreCertification of dental services, if required.
The Pre-Existing Conditions Exclusion described in
this booklet does not apply to dental benefits.
2. You must pay for your dental services up front,
directly to the Non-Preferred Dentist, and then
file for reimbursement, less any applicable
Calendar Year Deductible and Copay, from Blue
Cross and Blue Shield of Alabama. A NonPreferred Dentist may offer to file your claim for
you, but it is your responsibility to see that the
claim is filed correctly and in a timely manner.
The Preferred Dentist Dental Plan administered by
Blue Cross and Blue Shield of Alabama allows the
Plan to use its purchasing power to negotiate with
dental care providers. Negotiated savings are passed
on to you through increased benefits when you use a
Preferred Dentist.
The level of benefits you receive under the Dental
Plan will vary depending on whether services are
received from a Preferred Dentist or a Non-Preferred
Dentist.
3. Blue Cross and Blue Shield of Alabama will pay
only the Preferred Dentist negotiated fee. You
will be responsible for paying the difference
between the Preferred Dentist negotiated fee and
the actual charges of the Non-Preferred Dentist,
plus any applicable Calendar Year Deductible
and Copay.
If you live outside of the Preferred Dentist Network
Area, you will still receive benefits for dental
services, but you may wish to make arrangements to
receive benefits from a Preferred Dentist in order to
maximize your benefits.
PREFERRED DENTIST DIRECTORY
PREFERRED DENTIST BENEFITS
A provider directory listing the network of Preferred
Dentists is available online at the website
www.bcbsal.com. From time to time providers are
added and deleted from the network. It is your
responsibility to check with your dentist prior to
treatment to determine that the provider is still a
Preferred Dentist.
Services rendered and received from a dentist who
participates in the Preferred Dentist program are
eligible for Preferred Dentist Benefits. There are
several advantages to using a Preferred Dentist:
1. The Preferred Dentist will arrange for PreCertification of all dental services, if required,
and will file your claim for you.
FREEDOM OF CHOICE
2. The Preferred Dentist has agreed to accept a
negotiated fee for dental services as payment in
full, except for any applicable Calendar Year
Deductible or Copay.
3. The Preferred Dentist will not require that you
pay for dental services up front. You may be
required to pay up front any applicable Calendar
Year Deductible or Copay, but the Preferred
Dentist will file for the remaining balance
directly with Blue Cross and Blue Shield of
Alabama.
You are not required to use a Preferred Dentist under
the Dental Plan. You may choose to use a dentist
who does not participate in the Preferred Dentist
program, or you may live outside the Preferred
Dentist Network Area and find it inconvenient to use
a Preferred Dentist. The increased benefits are not
available for Non-Preferred Dentists.
30
DENTAL PLAN BENEFITS
FOR COVERED SERVICES
PREFERRED
DENTAL BENEFITS
NON-PREFERRED
DENTAL BENEFITS
DENTAL PLAN CALENDAR YEAR MAXIMUM BENEFIT
All dental Covered Services are limited to a Calendar Year Maximum Benefit of $1,000 per Member. Other
Maximum Benefit limitations may also apply.
DIAGNOSTIC AND PREVENTIVE SERVICES
Dental examinations, including treatment plan, limited to
a Maximum Benefit of twice per Calendar Year
Full mouth dental X-rays, limited to a Maximum Benefit
of once during any 36 consecutive months
Bite-wing X-ray examinations, limited to a Maximum
Benefit of twice per Calendar Year
Other dental X-rays Medically Necessary for the
diagnosis of a specific condition
Routine teeth cleaning and scaling, limited to a Maximum
Benefit of twice per Calendar Year
Topical fluoride treatment for children up to age 19,
limited to a Maximum Benefit of twice per Calendar Year
Space maintainers (not of precious metals) to replace
permanently lost teeth for children up to age 19
Dental sealants applied to teeth numbers 3, 14, 19 and 30,
limited to one application per tooth each 48 months and
limited to a Maximum Benefit of $20 per tooth for the
first permanent molars for children up to age 14
Plan pays 100%;
no Deductible
Plan pays 100% of the
Preferred Dentist
negotiated fee
(The Member is
responsible for any
charges over the amount
paid by the Dental Plan)
DENTAL PLAN CALENDAR YEAR DEDUCTIBLE
Restorative, supplemental, endodontic, prosthetic and periodontic services are subject to a $25 Calendar Year
Deductible per Member, limited to three Deductibles per family.
RESTORATIVE, SUPPLEMENTAL AND ENDODONTIC SERVICES
Fillings of silver amalgam and synthetic materials
Simple tooth extractions
Endodontic treatment, including direct pulp capping,
removal of pulp and root canal treatment
Repairs to removable dentures
Emergency treatment for the relief of dental pain
Oral surgery, for treatment of fractures, abscesses in the
mouth, and for removal of impacted erupted teeth
General anesthesia in connection with surgery, drugs
injected or inhaled to relax you, lessen paid or make you
unconscious (but not analgesics), drugs given by local
infiltration, or nitrous oxide
31
Plan pays 80%, subject to
the $25 Calendar Year
Dental Deductible
Plan pays 80% of the
Preferred Dentist
negotiated fee, subject to
the $25 Calendar Year
Dental Deductible
(The Member is
responsible for any
charges over the amount
paid by the Dental Plan)
DENTAL PLAN BENEFITS
FOR COVERED SERVICES
PREFERRED
DENTAL BENEFITS
NON-PREFERRED
DENTAL BENEFITS
PROSTHETIC SERVICES
Full or partial dentures
Fixed or removable bridges
Inlays, onlays or crowns to restore diseased or
accidentally broken teeth, if less expensive fillings are not
adequate
Repair or re-cementing of crowns, inlays, bridgework or
dentures, including re-basing or re-lining of dentures
Addition of teeth to an existing full or partial denture or to
fixed bridgework when Medically Necessary to replace
additional natural teeth that have been extracted while the
Member is covered under the Plan, limited to a Maximum
Benefit of once every five years
Replacement of existing dentures, fixed bridgework or
crowns, but only if determined to be Medically Necessary
when the existing placement cannot be adjusted or fixed,
limited to a Maximum Benefit of once every five years
Plan pays 50%, subject to
the $25 Calendar Year
Dental Deductible
Plan pays 50% of the
Preferred Dentist
negotiated fee, subject to
the $25 Calendar Year
Dental Deductible
(The Member is
responsible for any
charges over the amount
paid by the Dental Plan)
PERIODONTIC SERVICES
Surgical periodontic examinations
Gingivectomy and gingivoplasty (removal of diseased
gum tissue and reconstruction of gums)
Osseous surgery including flap entry and closure (removal
of diseased bone)
Mucogingivoplasty surgery (surgical reconstruction of
gums and mucous membranes)
Management of acute infection and oral lesions (full
program for periodontal disease)
Plan pays 50%, subject to
the $25 Calendar Year
Dental Deductible
Plan pays 50% of the
Preferred Dentist
negotiated fee, subject to
the $25 Calendar Year
Dental Deductible
(The Member is
responsible for any
charges over the amount
paid by the Dental Plan)
PRESCRIPTION DRUGS FOR DENTAL SERVICES
Prescription drugs for dental services, such as antibiotics or pain medications, are covered under the prescription
drug benefits of the Health Plan.
32
DENTAL PLAN BENEFIT LIMITATIONS
AND EXCLUSIONS
When there are two or more methods of treating a
condition, payment for a Covered Service will be
based upon the charges for the least expensive
course of treatment.
8. Treatment of the teeth or gums for cosmetic
purposes.
9. Prosthetics, including bridges and crowns,
started or under way prior to the Member’s
Effective Date under the Plan.
The following situations, conditions, services and
expenses are not covered under any part of your
Dental Plan:
10. Re-basing or re-lining of a denture less than six
months after the first placement, and not more
than one re-basing or relining in any two-year
period.
1. Anything excluded under the section of this
booklet titled Exclusions By Plan Provision.
2. Any service or expense covered under the
Health Plan schedule of benefits.
11. Replacement of lost or stolen prosthetics or
replacement of prosthetics less than five years
after a placement.
3. Any service or expense that is not performed by
a dentist, oral surgeon or a dental hygienist.
12. A new denture or bridgework if the existing
device can be made serviceable.
4. Any service or expense for which supporting
proof of loss has not been properly submitted.
Proof of loss may include clinical reports, charts,
and X-rays.
13. Procedures, restorations and appliances to
change vertical dimension or to restore proper
contact between opposing teeth.
5. Any service or expense related to the treatment
of Temporomandibular Joint (TMJ) disorders;
refer to the section titled Health Plan Covered
Services for additional information.
14. Any expense paid in whole or in part by any
other provision of the Health Plan.
15. Any expense in excess of the Allowed Amount.
16. Gold foil restorations or space maintainers made
of precious metals.
6. Anesthetic services performed by a dentist other
than the attending dentist or the attending
dentist’s assistant.
17. Orthodontia performed exclusively on primary
teeth.
7. Gold fillings, gold foil restorations or space
maintainers made of precious metals. The Plan
covers fillings of silver amalgam only, and
composite (tooth-colored) fillings in the smile
line.
18. Any expense for oral hygiene or dietary
information.
19. Any expense for plaque or infection control.
20. Any expense for implants or implantology.
21. Any expense for orthodontics or orthodontia.
33
GENERAL PLAN PROVISIONS
MEDICAL NECESSITY
Benefits are provided only for those Covered
Services determined by the Claims Administrator to
be Medically Necessary.
To be Medically
Necessary the service or supplies must at a minimum
be: (1) consistent with the diagnosis and treatment
of your condition; (2) in accordance with standards
of good medical practice and generally recognized
professional
standards;
(3)
approved
for
reimbursement by the Health Care Financing
Administration (Centers for Medicare and Medicaid
Services) (Medicare); (4) performed in the least
costly setting required by your condition; (5) not
primarily for the convenience of you or your
Physician; and (6) not Experimental or Investigative.
Evidence to help determine whether the services are
Medically Necessary may be required before
benefits are provided.
If the surgical care consists of two or more separate
and unrelated procedures performed during the same
session, the Plan will pay only for the procedure
with the largest Allowed Amount, and one-half (1/2)
of the Allowed Amount for each of the other
procedures.
When two surgeons in different specialties operate
in the same operative field as co-surgeons with each
assisting the other, the Plan’s payment will be made
at 150% of the Allowed Amount for the surgical
procedure, in which case the services of an assisting
surgeon would not be Covered Services, as the cosurgeons assist each other.
If care is rendered for multiple births during the
same Pregnancy, the Plan will pay the largest
Allowed Amount regardless of the number of babies
delivered or method(s) of delivery.
ALLOWED AMOUNT
LIMITATION OF LIABILITY
The Allowed Amount for all Covered Services is
determined by the Claims Administrator. The
Claims Administrator relies upon relative value
schedules which list procedures and corresponding
values upon which the specific allowance amount is
based. The Allowed Amount may not correspond to
the usual or customary charge made by a Physician,
Hospital, Dentist or other medical provider or by
other Physicians and medical providers in any
geographic area. In no case will the Allowed
Amount exceed the limits established in this Plan.
The USA Health & Dental Plan benefits are not
insured. The benefits provided by the USA Health
& Dental Plan are paid as a general obligation of the
University of South Alabama. Notwithstanding any
provision described in this document, the Plan will
not create a debt for the State of Alabama in
accordance with the State Constitution.
The University has the power and authority to make
additional rules and regulations concerning
eligibility and benefits, and reserves the right to
interpret the Plan and make final determinations
with regard to all matters.
Benefits for Covered Services are paid at the
Allowed Amount based on the fee schedule the
Administrator has contracted with its network
providers. The provider has agreed to accept a
negotiated fee for Covered Services. Members
receiving benefits for Covered Services from Blue
Cross and Blue Shield Providers are not responsible
for amounts billed in excess of this fee, except for
any applicable Deductible or Copay. The Member is
responsible for the amount billed in excess of the
Allowed Amount, plus any applicable Deductible or
Copay, for services obtained from a nonparticipating provider.
The University reserves the right to change, modify
and terminate any and all benefits at its sole
discretion. The University reserves the right to
change, modify and terminate any and all benefits
for any class of employees and dependents at its sole
discretion.
Eligibility and benefits are not
guaranteed and continue on a month to month basis
subject to change by the University. In the event of
Plan termination, all Employee and dependent rights
to benefits under the Plan will end effective with the
date of termination.
If surgical care rendered consists of two or more
related procedures performed during the same
operative session, the Plan will pay only for the
procedure with the largest Allowed Amount.
The USA Health Plan Management Committee is
charged with the responsibility and authority for
management of the USA Health Plan as authorized
in the Plan document.
34
COORDINATION OF BENEFITS (COB)
The University has in this Member Handbook tried
to summarize as accurately as possible all pertinent
provisions of the Plan as of the date this Member
Handbook was prepared. However, in the event of
any conflict between this USA Health Plan Member
Handbook and regulations and administrative
procedures, the University reserves the right to make
final and conclusive determination.
If you or an Eligible Dependent have coverage under
another group health plan, this Plan will coordinate
its benefits with those of the other plan to prevent
situations where benefits paid total more than 100%
of the covered expenses incurred.
Coordination of benefits requires that the Claims
Administrator determine which plan pays first (the
primary plan) and which plan pays second (the
secondary plan). If this Plan is primary, it will pay
the full benefits due, subject to Plan provisions and
limitations and any applicable Deductible, Copay
and Maximum Benefit. If this Plan is secondary, the
benefits it would have paid will be reduced to
account for the benefits provided by the other plan.
The relationships between the University of South
Alabama, the USA Health Plan, medical services
providers and Claims Administrator are independent
contractor relationships.
Neither the University of South Alabama nor the
USA Health Plan is liable for any claim or demand
on account of damages arising out of, or in any
manner connected with, any injuries suffered by the
Member while receiving care from any Blue Cross
and Blue Shield Provider or any other provider.
The Plan will not coordinate benefits if no benefits
are available. If services are not covered under this
Plan because they have been received from NonBlue Cross and Blue Shield Providers or Out-ofNetwork where no benefits are paid for Non-Plan or
Out-of-Network services, this Plan will not pay
benefits, even if the provider is an approved provider
under the Member’s other coverage.
RIGHT TO RECEIVE AND RELEASE INFORMATION
To ensure that benefits are paid correctly, the Claims
Administrator must receive information from
providers of medical services and from insurance
companies with whom benefits are coordinated. To
determine if a claim should be paid or denied, or
whether other parties are legally responsible for
some or all of the expense, the Claims Administrator
may exchange information with medical providers or
other health Claims Administrators.
Plans with which coverage is coordinated include:
(1) group insurance or any other arrangement of
group coverage, whether insured or self-funded; (2)
coverage provided under any government program
or required by any statute (except Medicaid); and (3)
Medicare, but only with regard to Employees
eligible for Medicare (this Plan is primary).
By enrolling in this Plan, you authorize the Claims
Administrator to obtain, use and release all records
about you and your Eligible Dependents that are
needed in the administration of the Plan. You accept
your obligation to provide to the Claims
Administrator information on other group health
insurance, other parties who may be legally
responsible for medical expenses, Change-In-Status
Events, and other reasonable information requested
or required.
COB Provision – If the other plan has no coordination
of benefits provision, it is primary. If both plans include
this provision, the following conditions apply in
determining which plan is primary:
Employee/Dependent Rule – The plan covering the
Member as an employee is primary over the plan
covering the Member as a dependent.
Active/Inactive Employee Rule – The plan
covering the Member as an active employee is
primary over the plan covering the Member as an
inactive employee (laid off or retired).
If you or any medical provider refuses to provide
information requested, this Plan may deny benefits.
The Claims Administrator and the University of
South Alabama strive to keep all information
confidential.
This Plan and/or the Claims
Administrator will not be held liable for the use or
misuse of information provided to other parties.
Dependent Child of Parents Not Separated or
Divorced – If both plans cover the Member as a
dependent child, the plan of the parent whose
birthday falls earlier in the year will be primary. If
the parents have the same birthday, the plan that has
covered the parent longer is the primary plan.
35
The Employee or Dependent may elect Medicare as
primary coverage, in which case this Plan will not
pay any benefits. An Employee electing Medicare
as primary coverage may have a Medicare
supplement contract but the University is not
allowed under the law to pay for such a contract.
Dependent Child of Separated or Divorced
Parents – If there is a court order that specifically
states that one parent must provide the dependent
child’s health expenses, that parent’s plan is
primary. In the absence of a court order, when two
or more plans cover the Member as a dependent
child, benefits are determined in this order:
1. First, the plan of the parent with custody.
Refer to the section titled “Creditable Drug
Coverage Notice” for additional information.
2. Then, the plan of the spouse of the parent with
custody.
UTILIZATION REVIEW
3. Last, the plan of the parent without custody.
Utilization review refers to the process conducted by
the Claims Administrator to ensure the appropriate
management and utilization of medical resources.
Review may be performed prior to, concurrent with
or retrospective of service in order to determine the
most appropriate treatment setting for the patient’s
severity of Illness. Review will also occur to
determine Medical Necessity and clinical outcome.
Payment of services may be denied if the services
fall outside the utilization review guidelines or are
not part of the schedule of benefits.
Longer/Shorter Length of Coverage Rule – If
none of the above rules determines the order of
payment, the plan covering the Member the longer
time is primary.
When this Plan is secondary, benefits will be
provided up to the Allowed Amount that exceeds the
payments of the primary plan, but in no case shall
the benefits exceed the lesser of: (1) what this Plan
would have paid in the absence of other coverage;
or, (2) the expenses the Member was obligated to
pay, which are covered in full or part by one of the
plans involved.
After the initial Pre-Certification of Hospital
admission, the Claims Administrator may contact
the attending Physician to determine if continued inpatient days are Medically Necessary. Any days not
certified as Medically Necessary will not be covered
by the Plan.
In some instances, a Member may be covered as an
employee under a Blue Cross and Blue Shield of
Alabama plan, and as a dependent under a Blue
Cross and Blue Shield of Alabama plan, or as a
dependent under two Blue Cross and Blue Shield of
Alabama plans.
When this Plan coordinates
benefits, the benefits of the plan that covers the
Member in a primary capacity will prevail. If the
primary Blue Cross and Blue Shield of Alabama
plan has a higher Copay than this Plan, for example,
the Member will be responsible for that Copay.
SUBROGATION – THE RIGHT TO RECOVER FROM
A RESPONSIBLE THIRD PARTY
If the Plan pays or provides any benefits for any
Member, the Plan is subrogated to all rights of
recovery which the Member has in contract, tort, or
otherwise against any person or organization for the
amount of benefits the Plan has paid or provided.
That means the Plan may use your right to recover
money from that other person or organization.
MEDICARE COORDINATION OF BENEFITS
The Eligible Employee or Eligible Dependent eligible
for Medicare will continue to be covered for the same
benefits available to all Eligible Employees. This
Plan will be primary and will pay its benefits first.
Medicare will then pay for Medicare eligible
expenses, if any, not paid by the Plan.
In the event a third party may be legally liable for
expenses for which the Plan provides benefits, the
Claims Administrator may, at its discretion, pay
benefits to the Member and be entitled to subrogate
any claim the Member may have against the third
party to the full extent of the benefits.
If an Eligible Employee or Eligible Dependent
becomes eligible for Medicare benefits based solely
on End Stage Renal Disease (ESRD), this Plan will
be primary for the first 30 months of eligibility for
Medicare. After the first 30 months of eligibility for
Medicare, if the Eligible Employee or Eligible
Dependent is still eligible for Medicare due to ESRD
or for any other reason, Medicare will be primary.
The Member (or the Eligible Employee if the
Member is a minor) must complete a form indicating
agreement to the Plan’s right to recover and
authorizing the Plan to subrogate from the third
party or from any settlement the Member may
receive.
36
RIGHT OF REIMBURSEMENT
harmed by any other act or failure to act on your part
and, if you do, the Plan may suspend or terminate
payment of any further benefits.
Besides the right of subrogation, this Plan has a
separate right to be reimbursed or repaid from any
money you, including your family members, recover
for an injury or condition for which the Plan paid
benefits. This means that you promise to repay the
amount the Plan has paid or provided in benefits
from any money you recover. It also means that if
you recover money as a result of a claim or a
lawsuit, whether by settlement or otherwise, you
must repay the Plan. And, if you are paid by any
person or company besides the Plan, including the
person who injured you, that person's insurer, or
your own insurer, you must repay the Plan. In these
and all other cases, you must repay the Plan.
Every effort is made to process claims promptly and
correctly. If payments are made to you or to a
provider who furnished services or supplies to you,
and the Plan finds at a later date that the payments
were incorrect, you or the provider will be required
to repay any overpayment or the Plan may deduct
the amount of the overpayment from any future
payment to you or the provider.
RIGHT TO RECOVER PAYMENTS MADE IN ERROR
The University of South Alabama has the right to
recover any benefit amount paid in error, in excess
of Plan benefit limitations or due to failure of the
Member to provide timely information concerning
eligibility.
This Plan has the right to be reimbursed or repaid
first from any money you recover, even if you are
not paid for all of your claim for damages and you
aren't made whole for your loss. This means that you
promise to repay the Plan first even if the money you
recover is for (or said to be for) a loss besides Plan
benefits, such as pain and suffering. It also means
that you promise to repay the Plan first even if
another person or company has paid for part of your
loss. And it means that you promise to repay the
Plan first even if the person who recovers the money
is a minor. In these and all other cases, the Plan has
the right to first reimbursement or repayment out of
any recovery you receive from any source.
If incorrect payments are made to you or to a
medical provider, the amount of the overpayment
must be refunded, or will be deducted from any
future payment to you or the provider. The Claims
Administrator is authorized and empowered to
recover payments made in error by any appropriate
method, including legal action for collection.
RECEIPT OF PAYMENT SATISFIES OBLIGATION
The Claims Administrator’s agreement with some
providers requires the Plan to pay benefits directly to
them. On all other claims, the Plan may choose at
its option to pay either you or the provider. You
may assign benefits to a provider and the Plan will
pay directly to the provider. Payment to you or the
provider will be considered to satisfy the Plan’s
obligation to you. The Plan does not have to honor
any assignment of your claim to anyone, including a
provider. If you die, become incompetent, or are a
minor, the Plan will pay your estate, your guardian
or any relative that in the Plan’s judgment is entitled
to the payment. Payment of benefits to one of these
people will satisfy the Plan’s obligation to you.
RIGHT TO RECOVERY
You agree to furnish the Claims Administrator all
information that you have concerning your rights of
recovery or recoveries from other persons or
organizations and to fully assist and cooperate with
the Claims Administrator in protecting and obtaining
the Plan’s reimbursement and subrogation rights.
You or your attorney will notify the Claims
Administrator before filing any suit or settling any
claim, to enable the Plan to participate in the suit or
settlement to enforce the Plan’s rights. If you notify
the Claims Administrator so the Plan is able to
recover the amount of Plan benefit payments for
you, the Plan will share proportionately with you the
cost of any attorneys' fees charged you by your
attorney for obtaining the recovery.
HOW TO FILE A CLAIM FOR BENEFITS
In all cases, you should file a written claim with the
Claims Administrator listed below within 90 days of
incurring charges for Covered Services. Failure to
file a claim for benefits within 12 months of the date
the expense was incurred will result in denial of
benefits. Claim forms are available from the
University of South Alabama Human Resources
Department.
If you do not give the Claims Administrator that
notice, reimbursement or subrogation recovery under
this section will not be decreased by any fee for your
attorney. You further agree not to allow the Plan’s
reimbursement and subrogation rights to be limited or
37
Health Plan
APPEALS TO THE CLAIMS ADMINISTRATOR
In most cases the Blue Cross and Blue Shield
Provider will file a claim for you. If you do not use
a Blue Cross and Blue Shield Provider, or for some
expenses, you will need to file a claim. Mail claims
to:
There are a number of reasons why your claim may
be denied in whole or in part. You should carefully
read any correspondence received from the Claims
Administrator, and review this USA Health Plan
Member Handbook to ensure that you understand
the reason for the denial.
Blue Cross and Blue Shield of Alabama
PO Box 995
Birmingham, AL 35298
If you are dissatisfied with the handling of a claim or
have any questions or complaints, you may do one
or more of the following:
In all cases, the Member is responsible for ensuring
that the claim has been filed in a timely manner.
1. You may contact the Claims Administrator’s
Customer Service Department. The Claims
Administrator will help you with questions
about your coverage and benefits or investigate
any adverse benefit determination you might
have received.
Dental Plan
The Dental Plan does not require that you file a
claim when you use a Preferred Dentist. If you use a
Non-Preferred Dentist, a claim must be filed before
payment can be made. Refer to the section titled
Dental Plan Benefits for information on PreCertification of dental services and filing a claim for
benefits.
2. You may file an appeal if you have received an
adverse benefit determination.
The rules in this section explain how you or your
authorized representative may appeal any adverse
benefit determination. An adverse benefit
determination includes any one or more of the
following:
In all cases, the Member is responsible for ensuring
that the claim has been filed in a timely manner.
CLAIM INQUIRIES
1. any decision the Claims Administrator makes
with respect to a post-service claim that results
in your owing any money to your provider other
than Copays you make, or are required to make,
to your provider;
If you have a question about a claim, you should
contact the Claims Administrator:
Blue Cross and Blue Shield of Alabama
PO Box 995
Birmingham, AL 35298
1-800-253-9305
2. the Claims Administrator’s denial of a preservice claim; or,
3. an adverse concurrent care determination (for
example, the Claims Administrator denied your
request to extend previously approved care).
Regional Office:
Blue Cross and Blue Shield of Alabama
4750 Airport Boulevard
Mobile, AL 36608
(251) 344-2115
In all cases other than decisions by the Claims
Administrator to limit or reduce previously approved
care, you have 180 days following the Claims
Administrator’s adverse benefit determination within
which to submit an appeal.
You may also contact the University of South
Alabama Human Resources Department should you
have any questions or problems regarding your
benefits.
If you wish to file an appeal of an adverse benefit
determination relating to a post-service claim the
Claims Administrator recommends you use a form
developed for this purpose. The form will help you
provide the Claims Administrator with the
information that is needed to consider your appeal.
To get the form, you may call the Claims
Administrator’s Customer Service Department. You
may also go to the Claims Administrator’s Internet
website at www.bcbsal.com.
University of South Alabama
Human Resources Departments
University of South Alabama Campus ........ 460-6133
USA Medical Center ................................... 471-7325
USA Children’s and Women’s Hospital ..... 415-1604
38
care professional who has appropriate expertise. If
Blue Cross and Blue Shield consulted a health care
professional during its initial decision, that same
person or a subordinate of that person will not be
consulted during consideration of your appeal.
If you choose not to use the Claims Administrator’s
appeal form, you may send the Claims
Administrator a letter. Your letter must contain at
least the following information:
1. the patient’s name;
You must send your appeal to the following address:
If Blue Cross and Blue Shield needs more
information, you will be asked to provide it. In some
cases Blue Cross and Blue Shield may ask your
provider to furnish that information; you will be sent
a copy of the request. However, you will remain
responsible for seeing that Blue Cross and Blue
Shield gets the information. If Blue Cross and Blue
Shield does not get the information, it may be
necessary for Blue Cross and Blue Shield to deny
your appeal. Blue Cross and Blue Shield will
consider your appeal fully and fairly.
Blue Cross Blue Shield of Alabama
Attention: Customer Service Appeals
P. O. Box 12185
Birmingham, Alabama 35202-2185
If your appeal arises from Blue Cross and Blue
Shield’s denial of a post-service claim, Blue Cross
and Blue Shield will notify you of its decision within
60 days of the date on which you filed your appeal.
Please note that if you call or write Blue Cross and
Blue Shield without following the rules just
described for filing an appeal, Blue Cross and Blue
Shield will not treat your inquiry as an appeal.
If your appeal arises from Blue Cross and Blue
Shield’s denial of a pre-service claim, and if your
claim is urgent, Blue Cross and Blue Shield will
consider your appeal and notify you of its decision
within one business day or, if during a long
weekend, within 72 hours. If your pre-service claim
is not urgent, Blue Cross and Blue Shield will give
you a response within 30 days.
2. the patient’s contract number;
3. sufficient information to reasonably identify the
claim or claims being appealed, such as date of
service, provider name, procedure (if known),
and claim number (if available) – the best way
to satisfy this requirement is to include a copy of
your Claims Report with your appeal; and,
4. a statement that you are filing an appeal.
You may appeal an adverse benefit determination
relating to a pre-service claim in writing or over the
phone. If over the phone, you should call the Health
Management Department at 205-988-2245 (in
Birmingham) or 1-800-248-2342 (toll-free). If in
writing, you should send your letter to the following
address:
If your appeal arises out of a determination by Blue
Cross and Blue Shield to limit or reduce a hospital
stay or course of treatment that was previously
approved for a period of time or number of
treatments, (see Concurrent Care Determinations
above), Blue Cross and Blue Shield will make a
decision on your appeal as soon as possible, but in
any event before Blue Cross and Blue Shield
imposes the limit or reduction.
Blue Cross Blue Shield of Alabama
Attention: Health Management - Appeals
P. O. Box 2504
Birmingham, Alabama 35201-2504
Your written appeal should provide Blue Cross and
Blue Shield with your name, contract number, the
name of the facility or provider involved, and the
date or dates of service. Please note that if you call
or write Blue Cross and Blue Shield without
following the rules just described for filing an
appeal, Blue Cross and Blue Shield will not treat
your inquiry as an appeal.
If your appeal relates to Blue Cross and Blue
Shield’s decision not to extend a previously
approved length of stay or course of treatment Blue
Cross and Blue Shield will make a decision on your
appeal within one business day or 72 hours if over a
long weekend (in urgent pre-service cases), 30 days
(in non-urgent pre-service cases), or 60 days (in
post-service cases).
Blue Cross and Blue Shield will assign your appeal
to one or more persons within Blue Cross and Blue
Shield’s organization who are neither the persons
who made the initial determination nor subordinates
of those persons. If resolution of your appeal
requires Blue Cross and Blue Shield to make a
medical judgment (such as Medically Necessary),
Blue Cross and Blue Shield will consult a health
In some cases, Blue Cross and Blue Shield may ask
for additional time to process your appeal. If you do
not wish to give additional time, Blue Cross and
Blue Shield will go ahead and decide your appeal
based on the information it has. This may result in a
denial of your appeal.
39
REVIEW PROCEDURE WHEN A CLAIM IS DENIED
with all the terms and provisions of the USA Health
& Dental Plan, and has fully complied with the
appeal to the Claims Administrator and request for
review by the University, and has received a notice
of denial of benefits in writing from the University.
If, after you have followed the procedure for
appealing a denial to the Claims Administrator, you
are not satisfied, or believe the Claims Administrator
has denied your claim in error, you may request a
review of the claim denial. You, your beneficiary,
or a duly authorized representative, may request
review of any denial of a claim for benefits as
follows:
Further, no legal action may be commenced against
the Plan, the University of South Alabama or the
Claims Administrator, individually or collectively,
more than 90 days after the date of the USA Health
Plan Management Committee’s final decision on
your request for review.
1. You must first comply with the appeal procedure
to the Claims Administrator; all correspondence
concerning your appeal to the Claims
Administrator must be submitted as part of your
request for review by the University of South
Alabama.
Notwithstanding any statement herein to the
contrary, the University of South Alabama does not
waive any sovereign immunity provided by state and
federal constitutions, or other laws or provisions of
law. The agent for the service of legal process shall
be the Claims Administrator.
2. If you are not satisfied with the Claims
Administrator’s decision, you may request a
review of that decision within 60 days of the
Claims Administrator’s response to your appeal.
You may request a review, in writing, to the
Human Resources Department:
DELEGATION OF AUTHORITY
The USA Health & Dental Plan has delegated to Blue
Cross and Blue Shield of Alabama, the Claims
Administrator, the discretionary responsibility and
authority to determine claims under the Plan, to
construe, interpret and administer the Plan, and to
perform every other act necessary or appropriate in
connection with the provision of administrative
services. When the Claims Administrator makes
reasonable determinations that are neither arbitrary
nor capricious in administration of the Plan, those
determinations will be final and binding upon the
Members, subject only to the appeals procedure and
University review procedure as explained in this
booklet, and thereafter to judicial review to determine
whether the determination was arbitrary or capricious.
Human Resources Department -- Benefits
University of South Alabama
286 Administration Building
Mobile, AL 36688
3. Your request for review will be considered by
the USA Health Plan Management Committee
and you will receive a written response within
60 days or a reasonable period thereafter.
Decisions of the University of South Alabama
are based upon reasonable determinations in the
administration of the Plan, and are intended to
be upheld as neither arbitrary nor capricious if
challenged in court.
A request for review will not be considered if:
RELATIONSHIP OF PARTIES
1. The request is not in writing and submitted to
the Human Resources Department; or,
The relationship between the University of South
Alabama, the USA Health & Dental Plan
participating providers and the Claims Administrator
are independent contractor relationships. Network
providers and the Claims Administrator are not
agents or employees of the University nor the USA
Health & Dental Plan.
2. The request does not include a copy of the
Claims Administrator’s original appeal decision;
or,
3. The request is not filed within the 60-day limit
that starts on the date of the Claims
Administrator’s appeal decision.
Neither the University nor the USA Health & Dental
Plan is liable for any claim or demand on account of
damages arising out of, or in any manner connected
with, any injuries suffered by the Member while
receiving care from any Network Provider or any
other provider.
No action may be brought against the University of
South Alabama or the Claims Administrator unless,
prior to any action being brought, the Member for
whom benefits are claimed, or any provider of
medical services, care, treatment, or supplies for
which such benefits are claimed, has fully complied
40
FEDERAL LAWS AFFECTING YOUR BENEFITS
COBRA CONTINUATION OF COVERAGE
COBRA coverage will continue for up to a total of
18 months from the date of your termination of
employment or reduction in hours, assuming you
pay your premiums on time. If, apart from COBRA,
the University continues to provide coverage to you
after your termination of employment or reduction in
hours (regardless of whether such extended coverage
is permitted under the Plan), the extended coverage
you receive will ordinarily reduce the time period
over which you may buy COBRA benefits.
A federal law, the Consolidated Omnibus Budget
Reconciliation Act (COBRA), allows former
employees and dependents to continue their health
coverage under this Plan in certain circumstances
beyond the date on which their coverage would
otherwise have ceased. If COBRA applies, you may
be able to temporarily continue coverage under the
Plan beyond the point at which coverage would
otherwise end because of a life event known as a
“qualifying event.” After a qualifying event,
COBRA coverage may be offered to each person
who is a “qualified beneficiary.” You, your spouse,
and your dependent children could become qualified
beneficiaries if coverage under the Plan is lost
because of a qualifying event.
If you are on a leave of absence covered by the
Family and Medical Leave Act (FMLA), and you do
not return to work, you will be given the opportunity
to buy COBRA coverage. The period of your
COBRA coverage will begin when you fail to return
to work following the expiration of your FMLA
leave or you inform your employer that you do not
intend to return to work, whichever occurs first.
COBRA coverage can be particularly important for
several reasons. First, it will allow you to continue
group health care coverage beyond the point at
which you would ordinarily lose it. Second, it can
prevent you from incurring a break in coverage
(persons with 63-day breaks in creditable coverage
may be required to satisfy pre-existing condition
exclusion periods if they obtain health coverage
elsewhere). And third, it could allow you to qualify
for coverage under the Alabama Health Insurance
Program (AHIP). See the section below titled “When
COBRA Coverage Ends” for additional information.
You do not have to demonstrate evidence of
insurability to qualify for COBRA coverage.
COBRA RIGHTS FOR DEPENDENT SPOUSES: If
you are covered under the Plan as a spouse of an
Eligible Employee, you will become a qualified
beneficiary if you would otherwise lose coverage
under the Plan as a result of any of the following
events: (1) your spouse dies; (2) your spouse's hours
of employment are reduced; (3) your spouse's
employment ends for any reason other than his or
her gross misconduct; (4) your spouse becomes
enrolled in Medicare (under Part A, Part B, or both);
or (4) you become divorced from your spouse.
If your spouse cancels your coverage in anticipation
of divorce and a divorce later occurs, your divorce
may be a qualifying event even though you actually
lost coverage under the Plan earlier. If you timely
notify the Human Resources Department of your
divorce and can establish that your spouse canceled
your coverage in anticipation of divorce, COBRA
coverage may be available to you beginning on the
date of your divorce (but not for the period between
the date your coverage ended and the date of the
divorce). See the section below titled “Notice of
Qualifying Events” and “Notice Procedures” for
more information about your responsibility to give
timely notice of your divorce and the procedures for
doing so.
You will have to pay for COBRA coverage. Your
cost will equal the full cost of the coverage plus a
two percent administrative fee. Your cost may
change over time, as the cost of benefits under the
Plan changes. If the University stops providing
health care through Blue Cross and Blue Shield of
Alabama, Blue Cross and Blue Shield of Alabama
will stop administering your COBRA benefits. If
this happens, you should contact the Human
Resources Department to determine if you have
further rights under COBRA.
COBRA RIGHTS FOR EMPLOYEES: If you are an
Eligible Employee, you will become a qualified
beneficiary if you lose coverage under the Plan
because either one of the following qualifying events
happens: (1) your hours of employment are reduced,
or (2) your employment ends for any reason other
than your gross misconduct.
COBRA RIGHTS FOR DEPENDENT CHILDREN: If
you are covered under the Plan as a dependent child
of an Eligible Employee, you will become a
qualified beneficiary if you would otherwise lose
coverage under the Plan as a result of any of the
41
not be permitted to buy COBRA coverage as a result
of divorce or a child losing dependent status.
following events: (1) the parent-employee dies; (2)
the parent-employee’s hours of employment are
reduced; (3) the parent-employee’s employment
ends for any reason other than his or her gross
misconduct;(4) the parent-employee becomes
enrolled in Medicare (under Part A, Part B, or both);
(5) your parents become divorced; or (6) you lose
Eligible Dependent status under the Plan.
EXTENSION OF COVERAGE FOR DISABILITY: In
certain circumstances you can take advantage of a
special disability extension. If you or a covered
member of your family is or becomes disabled under
Title II (OASDI) or Title XVI (SSI) of the Social
Security Act and you timely notify the Human
Resources Department, the 18-month period of
COBRA coverage for the disabled person may be
extended to up to 11 additional months (for a total of
up to 29 months) or the date the disabled person
becomes covered by Medicare, whichever occurs
sooner. This 29-month period also applies to any
non-disabled family members who are receiving
COBRA coverage, regardless of whether the
disabled individual elects the 29-month period for
him or herself. The 29-month period will run from
the date of the termination of employment or
reduction in hours. For this disability extension to
apply, the disability must have started at some time
before the 60th day of COBRA coverage and must
last at least until the end of the 18-month period of
COBRA coverage.
If you are receiving benefits under the Plan pursuant
to a Qualified Medical Child Support Order, you are
entitled to the same rights under COBRA as a
dependent child of the Eligible Employee.
LENGTH OF COVERAGE FOR DEPENDENTS: If
you are an Eligible Dependent, the period of
COBRA coverage will generally last up to a total of
18 months in the case of a termination of
employment or reduction in hours and up to a total
of 36 months in the case of other qualifying events,
provided that premiums are paid on time.
If, however, the covered employee became enrolled
in Medicare before the end of his or her employment
or reduction in hours, COBRA coverage for the
covered spouse and dependent children will continue
for up to 36 months from the date of Medicare
enrollment or 18 months from the date of
termination of employment or reduction in hours,
whichever period ends last. For example, if an
Eligible Employee becomes enrolled in Medicare 8
months before the date on which his employment
terminates, COBRA coverage for his spouse and
children can last up to 28 months (36 months after
the date of Medicare enrollment minus 8 months
prior to the date of the qualifying event that is
termination of employment).
The cost for COBRA coverage after the 18th month
will be 150% of the full cost of coverage under the
Plan, assuming that the disabled person elects to be
covered under the disability extension. If the only
persons who elect the disability extension are nondisabled family members, the cost of coverage will
remain at 102% of the full cost of coverage.
For spouses and children, the disability extension
may be further extended to 36 months if another
qualifying event (death, divorce, enrollment in
Medicare, or loss of dependent status) occurs during
the 29-month period. See the following discussion
under “Extension of COBRA for a Second
Qualifying Event” for additional information.
NOTICE OF QUALIFYING EVENTS: You will be
offered COBRA coverage only after the Human
Resources Department has been notified that a
qualifying event has occurred. When the qualifying
event is a divorce or a child losing dependent status
under the Plan, you must timely notify the Human
Resources Department of the qualifying event. You
must provide this notice within 60 days of the event
or within 60 days of the date on which coverage
would be lost because of the event, whichever is
later. Refer to the section below titled “Notice
Procedures” for information about the notice
procedures you must use to give this notice. If you
do not follow these notice procedures or if you do
not give the Human Resources Department notice of
your divorce or a child losing dependent status under
the plan within the 60-day notice period, you will
For this disability extension of COBRA coverage to
apply, you must give the Human Resources
Department timely notice of Social Security’s
disability determination before the end of the 18month period of COBRA coverage and within 60
days after the later of (1) the date of the initial
qualifying event, (2) the date on which coverage
would be lost because of the initial qualifying event,
or (3) the date of Social Security’s determination.
You must also notify the Human Resources
Department within 30 days of any revocation of
Social Security disability benefits. See the section
below titled “Notice Procedures” for additional
information. If you do not follow these notice
42
procedures or if you do not give the Human
Resources Department notice of Social Security’s
disability determination within the required notice
period, you will not be entitled to this disability
extension of COBRA coverage.
received by the Human Resources Department no
later than the last day of the required 60-day notice
period unless you mail it. If mailed, your notice must
be postmarked no later than the last day of the
required 60-day notice period.
EXTENSION OF COBRA FOR A SECOND
QUALIFYING EVENT: In certain circumstances
spouses and children can take advantage of a special
second qualifying event extension. For spouses and
children receiving COBRA coverage, the 18-month
period may be extended to 36 months if another
qualifying event occurs during the 18-month period,
if you give the Human Resources Department timely
notice of the second qualifying event. The 36-month
period will run from the date of the termination of
employment or reduction in hours.
For your notice of an initial qualifying event that is a
divorce or a child losing dependent status under the
Plan and for your notice of a second qualifying
event, you must mail or hand deliver your notice to
the Human Resources Department at the address
listed on page 1of this booklet. Your notice must
state (1) the name of the Plan, (2) the Eligible
Employee’s or Retiree’s name and address, (3) the
name(s) and address(es) of all qualified
beneficiary(ies), (4) the initial qualifying event and
the date of the event, and (5), when applicable, the
second qualifying event and the date of the event. If
the initial or second qualifying event is a divorce,
your notice must include a copy of the divorce
decree.
This extension is available to spouses and children
receiving COBRA coverage if the covered
Employee or former Employee dies, becomes
enrolled in Medicare (under Part A, Part B, or both),
or gets divorced, or if the child stops being eligible
under the plan as an Eligible Dependent, but only if
the event would have caused the spouse or child to
lose coverage under the plan had the first qualifying
event not occurred. For example, if an Eligible
Employee is terminated from employment, elects
family coverage under COBRA, and then later
enrolls in Medicare, this second event will rarely be
a second qualifying event that would entitle the
spouse and children to extended COBRA coverage.
This is so because, for almost all plans that are
subject to COBRA, this event would not cause the
spouse or dependent children to lose coverage under
the Plan if the covered employee had not been
terminated from employment.
For your notice of Social Security’s disability
determination, if you are instructed to send your
COBRA premiums to Blue Cross, you must mail or
hand deliver your notice to Blue Cross at the
following address: Blue Cross and Blue Shield of
Alabama, Attention: Customer Accounts, 450
Riverchase Parkway East, Birmingham, Alabama
35298-0001 or fax your notice to Blue Cross at 1205-220-6884 or (toll-free) 1-888-810-6884. Your
notice must state (1) the name of the Plan, (2) the
Eligible Employee’s or Retiree’s name and address,
(3) the name(s) and address(es) of all qualified
beneficiary(ies), (4) the qualifying event and the date
of the event, (5) the name of the disabled person, (6)
the date the disabled person became disabled, and
(7) the date of Social Security’s determination of
disability. Your notice must also include a copy of
Social Security's disability determination.
NOTICE OF SECOND QUALIFYING EVENTS: For
this 18-month extension to apply, you must give the
Human Resources Department timely notice of the
second qualifying event within 60 days after the
event occurs or within 60 days after the date on
which coverage would be lost because of the event,
whichever is later. See the section below titled
“Notice Procedures” for additional information. If
you do not follow these notice procedures or if you
do not give the Human Resources Department notice
of the second qualifying event within the required
60-day notice period, you will not be entitled to an
extension of COBRA coverage as a result of the
second qualifying event.
ADDING NEW DEPENDENTS TO COBRA: You may
add new dependents to your COBRA coverage
under the same eligibility rules that apply to Eligible
Employees. In addition, except as explained below,
any new dependents that you add to your coverage
will not have independent COBRA rights. That
means, for example, that if you die, they will not be
able to continue coverage.
If you are the covered employee and you acquire a
child by birth or placement for adoption while you
are receiving COBRA coverage, then your new child
will have independent COBRA rights. This means
that if you die, for example, your child may elect to
continue receiving COBRA benefits for up to 36
NOTICE PROCEDURES: Any notices that you give
must be in writing. Verbal notice, including notice
by telephone, is not acceptable. Your notice must be
43
elect COBRA coverage. You may elect COBRA
coverage on behalf of your spouse, and parents may
elect COBRA coverage on behalf of their children.
An election to buy COBRA coverage will be
considered made on the date sent back to the Human
Resources Department.
months from the date on which your COBRA
benefits began.
If your new child is disabled within the 60-day
period beginning on the date of birth or placement of
adoption, the child may elect coverage under the
disability extension if you timely notify the Human
Resources Department of Social Security’s disability
determination as explained above. The election
should be made on the child’s behalf by the child’s
legal guardian.
Once the Human Resources Department has notified
the Claims Administrator that your coverage under
the Plan has ceased, the Claims Administrator will
retroactively terminate your coverage and rescind
payment of all claims incurred after the date
coverage ceased. If you elect to buy COBRA during
the 60-day election period, and if your premiums are
paid on time, the Claims Administrator will
retroactively reinstate your coverage and process
claims incurred during the 60-day election period.
MEDICARE AND COBRA COVERAGE: If you are
eligible for both Medicare and COBRA coverage,
you should consider whether it is more beneficial to
purchase a Medicare supplemental contract instead
of COBRA coverage. Your COBRA coverage may
be secondary to Medicare with respect to services or
supplies that are covered, or would be covered upon
proper application, under Parts A or B of Medicare.
This means that, regardless of whether you have
enrolled in Medicare, your COBRA coverage may
not cover most of your hospital and medical
expenses. If you think you will need both Medicare
and COBRA, you should enroll in Medicare on or
before the date on which you make your election to
buy COBRA coverage. If you do this, COBRA
coverage for your dependents will continue for a
period of 18 months from the date of your retirement
or 36 months from the date of your Medicare
enrollment, whichever period ends last. Your
COBRA coverage will continue for a period of 18
months. If you do not enroll in Medicare on or
before the date on which you make your election to
buy COBRA coverage, your COBRA benefits will
end when your Medicare coverage begins.
Because there may be a lag between the time your
coverage under the Plan ends and the time the
Claims Administrator learns of your loss of
coverage, it is possible that claims incurred during
the 60-day election period may be paid. If this
happens, you should not assume that you have
coverage under the Plan. The only way your
coverage will continue is if you elect to buy COBRA
and pay your premiums on time.
EARLY TERMINATION OF COBRA COVERAGE:
Your COBRA coverage will terminate early if any
of the following events occurs: (1) the University no
longer provides group health coverage to any of its
Employees; (2) you do not pay the premium for your
continuation coverage on time; (3) after electing
COBRA coverage, you become covered under
another group health plan that does not contain any
exclusion or limitation on any pre-existing condition
you may have or you have sufficient creditable
coverage to preclude application of the new plan’s
pre-existing condition exclusion period to you; (4)
after electing COBRA coverage, you become
enrolled in Medicare (under Part A, Part B, or both);
or, (5) you are covered under the additional 11month disability extension and there has been a final
determination that the disabled person is no longer
disabled for Social Security purposes.
Your covered dependents will have the opportunity
to continue their own COBRA coverage. If you do
not want both Medicare and COBRA for yourself,
your covered family members will still have the
option to buy COBRA.
COBRA ELECTION RULES: After the Human
Resources Department receives timely notice that a
qualifying event has occurred, the Human Resources
Department is responsible for (1) notifying you that
you have the option to buy COBRA, and (2) sending
you an application to buy COBRA coverage.
In addition, COBRA coverage can be terminated if
otherwise permitted under the terms of the Plan. For
example, if you submit fraudulent claims, your
coverage will terminate.
You have 60 days within which to elect to buy
COBRA coverage. The 60-day period begins to run
from the later of (1) the date you would lose
coverage under the plan, or (2), the date on which
the Human Resources Department notifies you that
you have the option to buy COBRA coverage. Each
qualified beneficiary has an independent right to
If you are buying COBRA coverage and you become
covered under a group health plan that contains a
pre-existing condition limitation or exclusion that
does apply to you (for example, you do not have
enough creditable coverage to preclude application
44
You may also qualify for coverage under state law.
In Alabama, you can continue coverage through the
Alabama Health Insurance Plan (AHIP). You can
reach AHIP by calling the State Employees’
Insurance Board in Montgomery. In other states, you
should call the state insurance department. If you
elect to buy a conversion contract instead of
enrolling in AHIP, you will not be able to enroll at a
later date in AHIP.
of the new plan's pre-existing condition exclusion
period to you), you should discuss the situation with
the sponsor of the new plan (usually the new
employer) to determine whether it makes sense
nonetheless for you to enroll in the new plan while
continuing to pay for COBRA coverage at the same
time. Since some plans limit the circumstances under
which employees and their families may enroll, it is
best to consult with the new employer concerning
the interaction of COBRA and the new employer’s
group health coverage.
By contrast, if COBRA coverage ends because you
stop paying for it, then you will not have any further
coverage under the group health plan and you will
not be eligible to buy conversion coverage (if
available) and you may not qualify for continued
coverage under any applicable state law program.
For example, in Alabama, you would not qualify for
continued coverage under AHIP.
CHANGES IN COBRA BENEFITS: COBRA benefits
will change when benefits under the Plan change. By
law, COBRA benefits are required to be the same as
those made available to similarly situated active
employees. If the University changes the group
coverage, coverage will also change for you.
COBRA PREMIUM PAYMENT: Your first COBRA
premium payment must be made no later than 45
days after you elect COBRA coverage. That
payment must include all premiums owed from the
date on which COBRA coverage began. This means
that your first premium could be larger than the
monthly premium that you will be required to pay
going forward. You are responsible for making sure
the amount of your first payment is correct. You
may contact the Human Resources Department to
confirm the correct amount of your first payment.
If you have any further questions about COBRA or
if you change marital status, or you or your
spouse or child changes address, please contact
the Human Resources Department. Additional
information about COBRA can also be found at the
website of the Employee Benefits Security
Administration of the United States Department of
Labor, www.dol.gov/ebsa.
CERTIFICATES OF CREDITABLE COVERAGE: The
Health Insurance Portability and Accountability Act
of 1996 (HIPAA) creates a concept known as
“creditable coverage.” Your coverage under this
Plan is considered creditable coverage. If you have
sufficient creditable coverage under this Plan and
you do not incur a break in coverage (63 continuous
days of no creditable coverage), you may be able to
reduce or eliminate the application of a pre-existing
illness exclusion in another health plan. At any time
up to 24 months after the date on which your
coverage ceases under the Plan, you may request a
copy of a certificate of creditable coverage. In order
to request this certificate, you or someone on your
behalf must call or write Blue Cross and Blue Shield
of Alabama Customer Service.
After you make your first payment for COBRA
coverage, you must make periodic payments for
each subsequent coverage period. Each of these
periodic payments is due on the first day of the
month for that coverage period. There is a grace
period of 30 days for all premium payments after the
first payment. However, if you pay a periodic
payment later than the first day of the coverage
period to which it applies, but before the end of the
grace period for the coverage period, any claim you
submit for benefits will be suspended as of the first
day of the coverage period and then processed by the
Plan only when the periodic payment is received. If
you fail to make a periodic payment before the end
of the grace period for that coverage period, you will
lose all rights to COBRA coverage under the plan.
FAMILY AND MEDICAL LEAVE
You may be eligible for family or medical leave and
to continue health coverage if you have been
employed for at least 12 months, and have worked a
minimum of 1,040 hours during the 12 month period
immediately preceding the commencement of the
leave.
Payment of your COBRA premiums is deemed
made on the day sent.
WHEN COBRA COVERAGE ENDS: If you exhaust
your COBRA coverage you may buy a conversion
health contract from Blue Cross. Please contact Blue
Cross to determine whether a conversion contract is
available. Conversion contracts have more limited
coverage than COBRA coverage.
If you become eligible for a family or medical leave
in accordance with the Family and Medical Leave
45
Act of 1993 (FMLA), your health coverage may be
continued for a maximum of 120 days during a 12
month period, for any of the following reasons:
will be considered your COBRA qualifying
event.
If continuation of coverage under FMLA has
terminated when you return to active employment
(within 120 days), the Pre-Existing Conditions
Exclusion waiting period is waived upon
reinstatement of coverage under the Plan.
1. To care for your child after birth or placement of
a child with you for adoption or state-action
foster care; so long as such leave is completed
within 12 months after the birth or placement of
the child.
If you are considering FMLA leave, or believe you
qualify for FMLA leave, you should contact your
supervisor and the Human Resources Department for
additional information.
2. To care for your spouse, child, stepchild or
parent who has a serious health condition.
3. For your own serious health condition.
Under FMLA, a “serious health condition” involves
inpatient Hospital treatment, continuing treatment by
a medical provider and a period of incapacity for
more than three (3) days. Examples of conditions
not considered to be “serious health conditions”
include Cosmetic treatments (unless there are
complications), routine office visits, and common
ailments without complications such as colds, flu,
earaches, headaches and upset stomachs. Pregnancy
is considered a “serious health condition” for the
purpose of FMLA.
UNIFORMED SERVICES LEAVE
The Uniformed Services Employment and
Reemployment Rights Act (USERRA) applies to
Employees who perform duty, voluntarily or
involuntarily, in the Uniformed Services.
The Uniformed Services include the U.S. Army,
Navy, Marine Corps, Air Force, Coast Guard, Army
National Guard, Air National Guard and Public
Health Service Commissioned Corps, and any other
category of persons designated by the President in
time of war or emergency.
To qualify for continuation of health and dental
coverage under FMLA, you must notify your
immediate supervisor and the Human Resources
Department of your intention to take an FMLA
leave, 30 days in advance of a foreseeable leave, and
within 2 days of taking an unplanned leave.
Uniformed Service includes active duty, active duty
training, inactive duty training, and any time away
from employment for the purpose of an examination
to determine fitness for duty.
Eligible Employees who will be absent from
employment for more than 30 days due to
Uniformed Services duty may elect to continue
coverage for themselves and their Eligible
Dependents for up to 24 months. Employees who
will be absent for less than 30 days will have their
coverage continued under the same provisions as if
they had remained under active employment.
To continue coverage during your FMLA leave, you
must continue to pay the Employee Contribution.
You and your Eligible Dependents are subject to all
provisions and limitations of the Plan during your
leave; anything in conflict with the provisions of the
FMLA will be construed in accordance with the
FMLA. If there are any changes to the Plan during
your leave, you will be notified in writing.
If you are eligible for rights under USERRA, you
must follow the procedure provided below:
Continuation of coverage under FMLA terminates
the earlier of:
1. Notify the Human Resources Department that
you are leaving your job for temporary duty in
the Uniformed Services. You may notify the
Human Resources Department verbally or in
writing, but you must do so in advance of
leaving employment unless it is an emergency
call-up or impossible by military necessity.
1. The date you return to work.
2. The date you notify your supervisor you are not
returning to work, in which case this date will be
considered your COBRA qualifying event.
3. The first day of the month for which you fail to
make payment of the Employee Contribution
within a 30-day grace period.
2. Notify the Human Resources Department of
your intention to continue your health and dental
coverage under USERRA. You will be notified
in writing of the required Contribution to
maintain coverage under the Plan.
4. The date coverage has been continued for a
maximum of 120 days, in which case this date
46
2. Creates or recognizes the existence of the named
child(ren)’s right to be enrolled and receive
medical benefits under the Employee’s plan of
benefits;
3. Make arrangements to pay monthly, or make
payment in advance of the required Contribution
to maintain coverage.
In the event you choose not to pay the Employee
Contribution during your leave, your coverage will
not be continued during the leave. Following your
discharge from Uniformed Service, you may be
eligible to apply for re-employment in accordance
with USERRA.
3. States the period to which the order applies;
4. States the name and last known mailing address
of the Employee and each child covered by the
order; and
5. Does not require this Plan to provide any type or
form of benefit or any option not otherwise
provided by the Plan.
You will be able to reinstate your coverage on the
day you return to work, subject to all provisions of
the Plan in effect at the time your coverage
reinstates.
Continuation of coverage
terminates the earlier of:
under
A medical child support order must be filed with the
Human Resources Department within 30 days of the
date of the order to be considered by the Plan. When
the Human Resources Department receives a
medical child support order, the order will be
reviewed to determine if it meets the definition of a
QMCSO. Within 30 days of receipt of the order, or
within a reasonable time thereafter, written notice
will be provided to the Employee of the Plan’s
decision. This notice will also be sent to the other
party or representative named in the order.
USERRA
1. The date you return to work.
2. The date you notify your supervisor you are not
returning to work, in which case you may be
eligible to continue coverage for any COBRA
period remaining.
3. The first day of the month for which you fail to
make payment of the required Contribution
within a 30-day grace period.
If a determination is made that the order is not
Qualified, the notice will provide the specific
reasons for that decision and the opportunity to
correct the order or appeal the decision.
4. The date coverage has been continued for a
maximum of 24 months.
If continuation of coverage under USERRA has
terminated when you return to active employment
(within 24 months), the Pre-Existing Conditions
Exclusion waiting period is waived upon
reinstatement of coverage under the Plan.
A medical support order filed on behalf of the
Employee’s stepchild who is not permanently
residing in the home of the Employee, is not a
QMCSO under this Plan.
If a determination is made that the order is a
QMCSO, the notice will provide instructions for
enrolling each child named in the order, and the Plan
provisions, limitations and exclusions that apply.
The University will impose a payroll deduction for
Dependent Coverage, if applicable.
QUALIFIED MEDICAL CHILD SUPPORT ORDERS
This Plan will, under certain circumstances, provide
coverage for children named in a court order as your
dependents. If you receive such an order, in cases of
divorce or assignment of paternity, it should be
submitted to the Human Resources Department for
review to determine that it is a Qualified Medical
Child Support Order (QMCSO).
This will be considered a Change-In-Status Event
for the purpose of enrolling the child(ren) with an
Effective Date the first of the month following the
date of the QMCSO.
A QMCSO is any judgment, decree or order,
including approval of a settlement agreement, issued
by a court of competent jurisdiction which:
1. Relates to health benefits and provides for the
named child(ren)’s health benefit coverage
under the Employee’s plan of benefits, pursuant
to a state domestic relations law, community
property law, or enforcement of a law relating to
medical child support as described in Section
1908 of the Social Security Act;
As part of its authority, the Plan has the discretion to
decide if an order meets or does not meet the
definition of a QMCSO, and the decision will be
binding and conclusive on all persons. If the order
requires that expenses for Covered Services, when
reimbursed, be paid to the child’s custodial parent,
legal guardian, or someone other than the Employee,
these expenses will be reimbursed to the individual
identified in the QMCSO.
47
PRIVACY NOTICE
The Plan may disclose your medical information to
its business associates to assist the Plan in these
activities.
This notice gives you information required by law
about the duties and privacy practices of the Plan to
protect the privacy of your medical information. The
Plan provides health benefits to you as described in
this Member Handbook. The Plan receives and
maintains your medical information in the course of
providing benefits to you. The Plan hires business
associates to help provide benefits. These business
associates also receive and maintain your medical
information in the course of assisting the Plan. The
University of South Alabama is the Plan Sponsor.
As Required By Law. For example, the Plan must
allow the U.S. Department of Health and Human
Services to audit Plan records. The Plan may also
disclose your medical information as authorized by
and to the extent necessary to comply with workers’
compensation or other similar laws.
To Business Associates. The Plan may disclose
your medical information to business associates the
Plan hires or retains to assist the Plan. Each
business associate of the Plan must agree in writing
to ensure the continuing confidentiality and security
of your medical information.
The Plan is required to follow the terms of this
notice until it is replaced. The Plan reserves the
right to change the terms of this notice at any time.
If the Plan makes changes to this notice, the Plan
will revise it and send a new notice to all subscribers
covered by the Plan at that time. The Plan reserves
the right to make the new changes apply to all your
medical information maintained by the Plan before
and after the effective date of the new notice.
To Plan Sponsor. The Plan may disclose to the
Plan Sponsor, in summary form, claims history and
other similar information.
Such summary
information does not disclose your name or other
distinguishing characteristics. The Plan may also
disclose to the Plan Sponsor the fact that you are
enrolled in, or disenrolled from the Plan. The Plan
may disclose your medical information to the Plan
Sponsor for Plan administrative functions that the
Plan Sponsor provides to the Plan if the Plan
Sponsor agrees in writing to ensure the continuing
confidentiality and security of your medical
information. The Plan Sponsor must also agree not
to use or disclose your medical information for
employment-related activities or for any other
benefit or benefit plans of the Plan Sponsor.
PURPOSES FOR WHICH THE PLAN MAY USE OR
DISCLOSE YOUR MEDICAL INFORMATION
WITHOUT YOUR CONSENT OR AUTHORIZATION:
The Plan may use and disclose your medical
information for the following purposes:
Health Providers’ Treatment Purposes. The Plan
may disclose your medical information to your
doctor, at the doctor’s request, for your treatment by
him.
Payment. The Plan may use or disclose your
medical information to pay claims for covered health
care services or to provide eligibility information to
your doctor when you receive treatment.
The Plan may also use and disclose your medical
information as follows:
1. To comply with legal proceedings, such as a
court or administrative order or subpoena.
Health Care Operations. The Plan may use or
disclose your medical information (1) to conduct
quality assessment and improvement activities, (2)
for underwriting, premium rating, or other activities
relating to the creation, renewal or replacement of a
contract of health insurance, (3) to authorize
business associates to perform data aggregation
services, (4) to engage in care coordination or case
management, and (5) to manage the Plan and
develop the Plan’s business.
2. To law enforcement officials for limited law
enforcement purposes.
3. To a family member, friend or other person, for
the purpose of helping you with your health care
or with payment for your health care, if you are
in a situation such as a medical emergency and
you cannot give your agreement to the Plan to
do this.
4. To your personal representatives appointed by
you or designated by applicable law.
Health Services. The Plan may use your medical
information to contact you to give you information
about treatment alternatives or other health-related
benefits and services that may be of interest to you.
5. For research purposes in limited circumstances.
6. To a coroner, medical examiner, or funeral
director about a deceased person.
48
4. To correct your medical information. In some
cases, the Plan does not have to agree to your
request.
7. To an organ procurement organization in limited
circumstances.
8. To avert a serious threat to your health or safety
or the health or safety of others.
5. To receive a list of disclosures of your medical
information that the Plan and its business
associates made for certain purposes for the last
6 years (but not for disclosures before April 14,
2003).
9. To a governmental agency authorized to oversee
the health care system or government programs.
10. To federal officials for lawful intelligence,
counterintelligence and other national security
purposes.
6. To send you a paper copy of this notice if you
received this notice by e-mail or on the internet.
11. To public health authorities for public health
purposes.
If you want to exercise any of these rights described
in this notice, contact the Human Resources
Department. The Plan will give you the necessary
information and forms for you to complete and
return. In some cases, the Plan may charge you a
nominal, cost-based fee to carry out your request.
12. To appropriate military authorities, if you are a
member of the armed forces.
USES AND DISCLOSURES WITH YOUR
PERMISSION: The Plan will not use or disclose
your medical information for any other purposes
unless you give the Plan your written authorization
to do so. If you give the Plan written authorization to
use or disclose your medical information for a
purpose that is not described in this notice, then, in
most cases, you may revoke it in writing at any time.
Your revocation will be effective for all your
medical information the Plan maintains, unless the
Plan has taken action in reliance on your
authorization.
COMPLAINTS: If you believe your privacy rights
have been violated by the Plan, you have the right to
complain to the Plan or to the Secretary of the U.S.
Department of Health and Human Services. You
may file a complaint with the Human Resources
Department. The University will not retaliate
against you if you choose to file a complaint with
the Plan or with the U.S. Department of Health and
Human Services.
YOUR RIGHTS TO PRIVACY: You may make a
written request to the Plan to do one or more of the
following concerning your medical information that
the Plan maintains:
CONTACT OFFICE: Additional copies of this notice
may be obtained from the Human Resources
Department. Additional information about privacy
practices may be obtained from the Claims
Administrator, Blue Cross and Blue Shield of
Alabama.
1. To put additional restrictions on the Plan’s use
and disclosure of your medical information. The
Plan does not have to agree to your request.
CREDITABLE DRUG COVERAGE NOTICE
YOUR PRESCRIPTION DRUG COVERAGE AND
MEDICARE: Please read this notice carefully, and
keep it where you can find it. This notice has
information about your current prescription drug
coverage with the USA Health & Dental Plan (the
Plan) and new prescription drug coverage available
January 1, 2006 for people with Medicare. It also
tells you where to find more information to help you
make decisions about your prescription drug
coverage.
2. To communicate with you in confidence about
your medical information by a different means
or at a different location than the Plan is
currently doing. The Plan does not have to
agree to your request unless such confidential
communications are necessary to avoid
endangering you and your request continues to
allow the Plan to collect premiums or Employee
Contributions and pay claims. Your request
must specify the alternative means or location to
communicate with you in confidence. Even
though you requested that the Plan communicate
with you in confidence, the Plan may give
subscribers cost information.
Starting January 1, 2006, new Medicare prescription
drug coverage will be available to everyone with
Medicare.
The University has determined that the prescription
drug coverage offered by the Plan is, on average,
expected to pay out as much as the standard
Medicare prescription drug coverage will pay.
3. To see and get copies of your medical
information. In limited cases, the Plan does not
have to agree to your request.
49
of the plans offering Medicare prescription drug
coverage in your area.
Read this notice carefully - it explains the options
you have under Medicare prescription drug
coverage, and can help you decide whether or not
you want to enroll.
You should also know that if you drop or lose your
coverage with the Plan and don’t enroll in Medicare
prescription drug coverage after your current
coverage ends, you may pay more to enroll in
Medicare prescription drug coverage later. If after
May 15, 2006, you go 63-days or longer without
prescription drug coverage that’s at least as good as
Medicare’s prescription drug coverage; your
monthly premium will go up at least 1% per month
for every month after May 15, 2006 that you did not
have that coverage. For example, if you go 19months without coverage, your premium will always
be at least 19% higher than what most other people
pay. You’ll have to pay this higher premium as long
as you have Medicare coverage. In addition, you
may have to wait until next November to enroll.
You may have heard about Medicare’s new
prescription drug coverage, and wondered how it
would affect you. The University has determined
that your prescription drug coverage with the Plan is,
on average for all plan participants, expected to pay
out as much as the standard Medicare prescription
drug coverage will pay.
Starting January 1, 2006, prescription drug coverage
will be available to everyone with Medicare through
Medicare prescription drug plans. All Medicare
prescription drug plans will provide at least a
standard level of coverage set by Medicare. Some
plans might also offer more coverage for a higher
monthly premium.
For more information about this notice or your
current prescription drug coverage, contact the
USA Human Resources Department. You may
receive this notice at other times in the future such as
before the next period you can enroll in Medicare
prescription drug coverage, and if this coverage
changes. You may also request a copy.
Because your existing coverage is on average at
least as good as standard Medicare prescription
drug coverage, you can keep this coverage and
not pay extra if you later decide to enroll in
Medicare coverage.
The USA Health Plan offers Medicare-eligible
participants with a Health Plan that provides
greater benefits for prescription drugs than does
the new Medicare Part D prescription drug
benefit. The Plan offers valuable coverage for
other health care services that may or may not be
covered by Medicare.
For more information about your options under
Medicare prescription drug coverage, read the
“Medicare & You 2006” handbook from Medicare.
You’ll get a copy of the handbook in the mail from
Medicare. You may also be contacted directly by
Medicare prescription drug plans. You can also get
more information about Medicare prescription drug
plans from these places:
• Visit www.medicare.gov for personalized help,
• Call your State Health Insurance Assistance
Program (see your copy of the Medicare & You
handbook for their telephone number),
• Call 1-800-MEDICARE (1-800-633-4227). TTY
users should call 1-877-486-2048.
For people with limited income and resources, extra
help paying for a Medicare prescription drug plan is
available. Information about this extra help is
available from the Social Security Administration
(SSA). For more information about this extra help,
visit SSA online at www.socialsecurity.gov, or call
1-800-772-1213 (TTY 1-800-325-0778).
There is no benefit on average for a participant to
take the Medicare Part D benefit and pay an
extra premium for that benefit.
People with Medicare can enroll in a Medicare
prescription drug plan from November 15, 2005
through May 15, 2006. However, because you have
existing prescription drug coverage that, on average,
is as good as Medicare coverage, you can choose to
join a Medicare prescription drug plan later. Each
year after that, you will have the opportunity to
enroll in a Medicare prescription drug plan between
November 15th through December 31st.
If you do decide to enroll in a Medicare prescription
drug plan and drop the Plan coverage, be aware that
you will not be able to get this coverage back at a
later date.
If you drop your coverage with the Plan, you will
not be able to get the coverage back later. You
should compare your current coverage, including
which drugs are covered, with the coverage and cost
50
SOUTHFLEX HEALTH AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
USING PRE-TAX DOLLARS FOR EXPENSES
USE IT OR LOSE IT POLICY
The University of South Alabama sponsors an
employee benefit program for Employees known as
a Health and Dependent Care Flexible Spending
Account (SouthFlex). SouthFlex allows you to set
aside a certain amount each year, pretax, for healthrelated expenses not reimbursed by any other
program or plan. You then use those pre-tax dollars
to reimburse yourself for out-of-pocket health care
expenses. Participation in SouthFlex is voluntary.
The Flexible Spending Account can save you money
by using pre-tax dollars, and can benefit you by
allowing you to save for health care expenses that
are not covered by your Plan. However, the amount
you choose to contribute requires careful planning.
Money you contribute to your SouthFlex account
must be used during the Calendar Year. Money
left in an account does not carry over to the next
year, and is not refundable at the end of the year. In
other words, if you do not use it, you will lose it.
Under SouthFlex, your contribution will be deducted
from your paycheck. Your contribution will be
deducted from your pay before taxes.
This
arrangement helps you because the benefits you elect
are nontaxable; you save Social Security and income
taxes on the amount of your salary reduction.
Funds assigned to the health care Flexible Spending
Account cannot be transferred to the dependent care
Flexible Spending Account under any circumstances.
Funds assigned to the dependent care Flexible
Spending Account cannot be transferred to the
health care Flexible Spending Account under any
circumstances.
This is only a summary of SouthFlex. You can obtain
additional information and forms at the website
www.preferredflex.com.
COORDINATION WITH HEALTH & DENTAL PLAN
PARTICIPATION IN THE PLAN
SouthFlex is administered by Blue Cross and Blue
Shield of Alabama, and is coordinated with the USA
Health & Dental Plan. Out-of-pocket expenses for
Eligible Employees and their Eligible Dependents
(such as Copays and Deductibles) will automatically
apply to your SouthFlex account. In addition, you
will be able to file to reimburse yourself from your
account for expenses for approved non-Covered
Services (such as over-the-counter drugs and
eyeglasses).
You may participate in SouthFlex if you are an
Employee. You do not have to enroll in the Health
& Dental Plan to participate in SouthFlex.
During the Open Enrollment Period, usually the
month of November, you may complete an election
form determining the amount you wish to contribute
to your SouthFlex account beginning the first of the
following year.
You may direct up to a maximum of $5,000 to your
SouthFlex account each year to pay for eligible
health care expenses.
ELIGIBLE HEALTH CARE EXPENSES
SouthFlex can be used to reimburse you for your
own health care expenses, as well as those of your
eligible dependents, as long as the expenses are:
You may direct up to a maximum of $5,000 to your
SouthFlex account each year to pay for dependent
day care expenses so you (and, if married, your
spouse) can work outside the home or attend school
full-time. If you and your spouse file income taxes
separately, the most either of you can put into the
program to pay for dependent day care expenses is
$2,500. Unpaid volunteer work or volunteer work
for a nominal salary does not qualify as work outside
the home.
1. amounts paid for “medical care” as described in
Internal Revenue Code Section 213(d);
2. not reimbursable under any other health plan in
which you participate; and
3. incurred after the date of your enrollment and
during the Calendar Year; however, if your
employment terminates during the Calendar
Year, health care expenses must be incurred
before your termination date (unless you elect
continuation of coverage under COBRA).
The amount you elect will be divided equally
depending on your pay schedule and will be
deducted from your pay before taxes are withheld.
This amount will be deposited into your spending
account.
51
For a more complete list of eligible expenses,
consult your personal tax advisor or refer to IRS
publication 502, Medical and Dental Expenses
which contains a list of deductible expenses. This
publication can be obtained through your local IRS
office or accessed over the internet at
www.preferredflex.com.
Expenses eligible under the SouthFlex program are
those not paid in full under any health care plan in
which either you or your Eligible Dependents
participate, including Deductibles, Copays and fees
over the Allowed Amount. Eligible expenses do not
include health, dental or life insurance premiums.
Following are examples of health care expenses that
are reimbursable by SouthFlex. This is a partial list
extracted from IRS publications and is subject to
change. Eligible health care expenses include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
NOTE: Misuse of spending account funds is a
violation of Internal Revenue Service regulations.
HEALTH CARE EXPENSES THAT ARE NOT
ELIGIBLE FOR REIMBURSEMENT
acupuncture
ambulance transportation expenses
artificial limbs
artificial teeth
birth control pills
braille books and magazines
car controls for handicapped
chiropractors
Christian Science practitioners
contact lenses, as well as the equipment and
materials required for using them
crutches
dental fees
doctors’ fees
drug and alcohol addiction treatment
eyeglasses
fertility enhancement (including in vitro
fertilization and surgery)
guide dogs
hearing aids
hospital services
lab fees
lead-based paint removal
learning disability tuition
nursing services
optometrists
oxygen
prescribed and over-the-counter medicines
psychoanalysis
special schools for the handicapped
sterilization
surgery (other than cosmetic surgery)
therapy (medical)
transplants of organs
transportation to/from health care provider
weight-loss plans prescribed by a Physician to
treat a specific disease
wheelchairs
x-rays
Although the Health FSA covers a wide variety of
health care expenses, there are some expenses that
are not eligible for payment. For example, expenses
you incur in connection with activities that are
merely beneficial to your general health and not
directly related to specific health care are not
reimbursable. And, as already noted, eligible
expenses do not include health, dental, or life
insurance premiums. Other types of health care that
are not eligible include:
1. expenses incurred for health clubs, spas and
weight loss programs (unless prescribed by a
physician solely for the purpose of treating an
illness or accident);
2. expenses for which you receive benefits from
any health, dental, vision or other health care
plan (see below for special rules pertaining to
HRAs);
3. most kinds of cosmetic health services and
supplies (unless medically necessary and not
covered by a health plan), hair transplants,
electrolysis, and teeth whitening; and,
4. dietary and herbal supplements such as vitamins,
fiber, and minerals (unless prescribed by a
physician solely for the purpose of treating an
illness).
Expenses are eligible for reimbursement from the
FSA only if they are expenses paid for the diagnosis,
cure, mitigation, treatment, or prevention of disease,
or for the purpose of affecting any structure or
function of the body.
ELIGIBLE DEPENDENT CARE EXPENSES
SouthFlex can be used to reimburse you for your
dependent expenses, as long as the expenses are:
1. incurred so that you and your spouse (if you are
married) can work or attend school full-time;
52
REIMBURSEMENT PROCEDURE
2. incurred for services relating to the care of a
child under the age of 13, or your Disabled child
or adult who lives with the employee for more
than half of the taxable year;
3. incurred after the date of your enrollment and
during the Calendar Year; however, if your
employment terminates during the Calendar
Year, dependent care expenses must be incurred
before your termination.
If you (or your health care provider) file a primary
health or dental claim with Blue Cross and Blue
Shield of Alabama and no secondary coverage is
reflected on your contract, it will not be necessary to
file for reimbursement of any non-paid amount.
These non-paid health expenses will automatically
be filed and processed under your Health FSA if the
funds are available (minimum reimbursement
amount is $10). For other eligible expenses, you
must file a Request for Reimbursement.
Following are examples of dependent care expenses
that are reimbursable by SouthFlex. Eligible
dependent care expenses include:
1. expenses incurred for dependent day care that
allow you (and if married, your spouse) to work
or attend school full-time
2. licensed nursery school or day care center for
children, provided the facility complies with all
applicable state and local laws and regulations,
provides care for seven or more individuals, and
receives a fee for providing day care services
3. costs for dependent care services in or outside
your home
4. costs for household services which are in part
attributable to the care of the dependent.
You may obtain a Request for Reimbursement form
from the website www.preferredflex.com. Simply
fill it out and attach Explanation of Benefits (EOB)
forms, bills, invoices, receipts, or other supporting
statements showing the amount of the health-related
expenses or dependent care expenses for which you
are claiming reimbursement. Send the Request for
Reimbursement form and attachments to the
Preferred Blue Customer Service Center at Post
Office Box 11586, Birmingham, Alabama 352021586. If the Preferred Blue Customer Service
Center receives a submission that does not qualify as
a Request for Reimbursement, it will notify you of
the additional information needed.
For expenses to be eligible for reimbursement, the
person you pay to provide care for your dependents
cannot be your spouse, another dependent, or a
family member under the age of 19. For more
information about eligible dependent care expenses,
refer to IRS Publication 503, Child and Dependent
Care Credit, which can be obtained at your local IRS
office or through the website www.irs.gov.
Requests for Reimbursement for eligible health care
and eligible dependent care expenses incurred in a
Calendar Year must be submitted by the close of the
timely filing period, April 15th of the following
Calendar Year. After the close of that period any
money in the account is forfeited unless subject to a
properly filed Request for Reimbursement or appeal.
GRACE PERIOD FOR THE “USE IT OR LOSE IT”
RULE UNDER THE HEALTH FSA
DEPENDENT CARE EXPENSES THAT ARE NOT
ELIGIBLE FOR REIMBURSEMENT
There is a grace period for the Health flexible
spending account only (this rule does not apply to
expenses under the dependent care flexible spending
account).
Certain dependent care expenses are not covered
under SouthFlex. Examples of ineligible expenses
include, but are not limited to:
1. any amounts you pay to a family member under
the age of 19 or any person you claim as a
dependent on your federal income tax return;
2. costs for any person caring for your dependents
when you or your spouse are not working;
3. transportation expenses;
4. child support payments;
5. education expenses for kindergarten and above
or overnight camp expenses;
6. food, clothing and entertainment;
7. cleaning and cooking services not provided by
the care provider.
Money remaining in the health flexible spending
account at the end of the Calendar Year may be
carried over and used to cover eligible expenses
incurred through March 15th of the next Calendar
Year. This is referred to as a grace period.
This does not eliminate the “use it or lose it” rule
altogether. Any unused amounts from the prior
Calendar Year that are not used to reimburse
expenses by the end of the grace period must be
forfeited.
53
SECTION 125 PREMIUM CONVERSION PLAN
BENEFITS OFFERED
The University of South Alabama sponsors an
employee benefit program for active Employees
known as a Section 125 Premium Conversion Plan.
The purpose of the Plan is to increase your
spendable income by reducing your taxes. Current
tax legislation allows employers to offer Employees
the benefit of having their Employee Contribution
for qualified benefit plans deducted from their
paychecks before taxes are taken out.
The Section 125 Premium Conversion Plan permits
you to pay your Employee Contribution for the USA
Health & Dental Plan with pre-tax dollars through
salary reduction rather than regular pay.
Since Social Security taxes are not withheld from
Employee Contributions paid under the Section 125
Premium Conversion Plan, your Social Security
retirement benefit may be slightly reduced.
Under the Premium Conversion Plan, your cost will
still be deducted from your paycheck.
The
difference is that your cost will be deducted from
your pay before taxes. This arrangement helps you
because the benefits you elect are nontaxable; you
save Social Security and income taxes on the amount
of your salary reduction.
Alternatively, you can pay for the same benefit with
after-tax dollars on a salary deduction basis. If you
elect not to participate in the plan, after-tax premium
coverage will be funded by an amount deducted
from your compensation which is sufficient to pay
for the coverage after withholding any applicable
federal, state, or Social Security taxes.
EFFECTIVE DATE
ENROLLMENT PERIODS
The Section 125 Premium Conversion Plan became
effective on November 1, 1987.
The Open Enrollment Period usually begins on
November 1st of each year and ends on November
30th of each year, for coverage effective at the
beginning of the following Calendar Year.
PARTICIPATION IN THE PLAN
You may participate in the Section 125 Premium
Conversion Plan if you are an employee of the
University of South Alabama who is eligible to
participate in the USA Health & Dental Plan. You
will become a participant in the Section 125
Premium Conversion Plan at the time you enroll in
the USA Health Plan.
TERMINATION OF EMPLOYMENT
If your employment with the University of South
Alabama is terminated during the Calendar Year,
your active participation in the Section 125 Premium
Conversion Plan will cease, and you will not be able
to make any more contributions to the plan, other
than as may be permitted under the COBRA
continuation of coverage provision.
You may request a benefit election form from the
Human Resources Department during the Open
Enrollment Period. At that time you may confirm or
change your choices made from the previous Plan
year for the coming Plan year beginning on the first
day of the next Calendar Year. You may at that time
elect to terminate your participation in the Section
125 Premium Conversion Plan, with changes
effective the first of the following Calendar Year. If
you fail to file a benefit election form as required,
you shall be deemed to have elected to continue the
same coverage by the same proportion of pre-tax or
after-tax premiums then in effect.
Your participation in the Section 125 Premium
Conversion Plan will terminate effective the first of
the month for which no Employee Contribution was
withheld from your paycheck.
54
CHANGE OF ELECTION
You may change your election for pre-tax premiums
only during the Open Enrollment Period, which is
usually the month of November each year, and then
only for the coming Calendar Year. There is an
important exception to this general rule: You may
change or revoke your previous election for pre-tax
premiums at any time during the Calendar Year due
to a Change-In-Status Event, provided that both the
revocation and new election are made on account of
and are consistent with one of the following ChangeIn-Status Events:
You must be able to provide written documentation
to verify the Change-In-Status Event.
If you have a Change-In-Status Event and wish to
change your election, you must submit an
Application to the Human Resources Department
within 30 days of the Change-In-Status Event.
Failure to do so within 30 days will result in the
changes in your election being applicable only to
months during which, or after, you have notified the
Human Resources Department.
No Employee Contribution refunds can be made
retroactive from the date the Change-In-Status Event
Application has been received and approved by the
Human Resources Department.
1. A change in your marital status (marriage,
divorce, legal separation or death of your
spouse).
2. A change in the number of your dependents
(birth or adoption of a child, death of a child,
obtaining legal custody or legal guardianship).
Elections for after-tax premiums through salary
deduction outside of the Section 125 Premium
Conversion Plan may be changed as permitted by the
University of South Alabama.
3. A change in your, or your spouse’s, employment
status (starting/ ending employment, changing
from part-time to full-time or vice versa, a strike
or lock-out, or taking or returning from an
unpaid leave of absence or leave under the
Family and Medical Leave Act or USERRA
during which your, or your spouse’s, coverage
terminated).
REVIEW PROCEDURE
A participant in the Premium Conversion Plan who
believes that a service, expense or determination of
eligibility has been wrongly denied in whole or in
part may request a review.
This request must be made within 30 days of the
date of notification of the denial. It must be in
writing and delivered to:
Human Resources
Department, University of South Alabama, 286
Administration Building, Mobile, AL, 36688.
4. Exhaustion of your coverage period under a
previous employer’s COBRA continuation.
5. A significant change in the cost of or coverage
provided by your spouse’s employer-sponsored
health plan, or a significant change in the cost of
or coverage provided by this Plan.
The USA Health Plan Management Committee will
review your claim and the information you provided
and will send to you a notice of decision within 30
days of receipt of your request for review.
6. A change in the eligibility status of a dependent
child (marriage of the child, child reaching the
maximum age for coverage under the Plan, child
meeting or no longer meeting the definition of a
Full-Time Student, or child becoming eligible
under another health plan).
ADMINISTRATION
The Section 125 Premium Conversion Plan is
administered by the University of South Alabama.
All costs associated with the administration of this
plan are paid for by the University of South
Alabama.
7. An end to the Disability of a Disabled child
enrolled as your dependent under the Plan.
8. A change in your residence or work site, or that
of a spouse or dependent, which affects ability to
access benefits under this or another employersponsored health plan.
9. A change required by a court order.
10. Your, or your dependent’s, entitlement to
Medicare or Medicaid.
55
DEFINITIONS
Some words and terms have a specific meaning and are capitalized when used in this Member Handbook. This
section will assist you in understanding the specific meaning of those words and terms. Please read this section
carefully.
6. Change-In-Status Event: A change in the
employment or personal status of an Employee
or dependent that permits or requires enrollment
or termination of coverage during a Special
Enrollment Period. The Human Resources
Department must be notified within 30 days of a
Change-In-Status Event.
1. Allowed Amount: The Allowed Amount for all
Covered Services is determined by the Claims
Administrator, who relies upon relative value
schedules
which
list
procedures
and
corresponding values upon which the specific
allowance amount is based. The Allowed
Amount may not correspond to the usual or
customary charge made by health care providers
in any specific geographic area. In no case will
the Allowed Amount exceed the limits
established in this Plan. Charges in excess of the
Allowed Amount are the responsibility of, and
must be paid by, the Member.
A Change-In-Status Event includes: (1) a change
in your marital status (marriage, divorce, legal
separation or death of a spouse); (2) a change in
the number of your dependents (birth or
adoption of a child, death of a child, obtaining
legal custody or guardianship); (3) a change in
your or your spouse’s, employment (starting /
ending employment, changing from part-time to
full-time, strike or lock-out, or taking or returning
from an unpaid or FMLA or USERRA leave of
absence during which your, or your spouse’s,
coverage terminated); (4) exhaustion of your
coverage period under a previous employer’s
COBRA continuation; (5) a significant change
in the cost of or coverage provided by your
spouse’s employer-sponsored health plan, or a
significant change in the cost of or coverage
provided by this Plan; (6) a change in the
eligibility status of a dependent child (marriage
of the child, child reaching the maximum age for
coverage under the Plan, child meeting or no
longer meeting the definition of a Full-Time
Student, or child becoming eligible under
another health plan); (7) An end to the Disability
of a Disabled child enrolled as your dependent
under the Plan; (8) a change in your residence or
work site, or that of a spouse or dependent,
which affects ability to access benefits under this
or another employer-sponsored health plan; (9) a
change required by a court order; and (10) your,
or your dependent’s, entitlement to Medicare or
Medicaid.
2. Application: The Employee’s or dependent’s
original written application form requesting
coverage under the Plan, together with any
supplemental information, accepted and
approved by the Human Resources Department.
The application requires all Eligible Dependents
be listed by name, evidence of dependent status,
and other information as required by the Human
Resources Department.
Acceptance of the
Application is evidenced by the issuance of an
identification card or by other written notice of
acceptance to the Employee.
3. Administrator: The corporation appointed by
the University of South Alabama to be
responsible for the functions and administration
of the USA Health Plan.
The Claims
Administrator is Blue Cross and Blue Shield of
Alabama.
4. Blue Cross and Blue Shield Provider: A
Hospital, Physician, outpatient clinic, health
center, pharmacy or other provider of medical
services who has a written agreement with the
Claims Administrator to provide services under
the Plan. Blue Cross and Blue Shield Providers
include USA Health System Providers, PMD
Providers in Alabama and BlueCard PPO
members outside of Alabama.
7. Claims Administrator: The corporation
appointed by the University of South Alabama
to be responsible for the functions and
administration of the USA Health Plan. The
Claims Administrator is Blue Cross and Blue
Shield of Alabama.
5. Calendar Year: The calendar year period of
January 1st through December 31st of any given
year.
56
12. Covered Services: Includes only the services,
supplies and expenses listed in this Member
Handbook as eligible for reimbursement.
Covered Services do not include any service,
supply or expense not specifically stated as a
Covered Service herein or eligible for
reimbursement; any service, supply or expense
which is specifically excluded; any amount in
excess of the Allowed Amount; and any charge
or amount in excess of a specifically stated Plan
Maximum Benefit.
8. COBRA: The Consolidated Omnibus Budget
Reconciliation Act of 1985 as amended, which
provides specific circumstances that allow for a
limited continuation of a Member’s coverage
beyond the date it would otherwise terminate.
9. Complications of Pregnancy: Any condition
resulting in Hospital confinement, the diagnosis
of which is distinct from pregnancy but is
adversely affected or caused by pregnancy, such
as acute nephritis, nephrosis, cardiac
decompensation, missed abortion and similar
conditions of comparable severity, non-elective
cesarean delivery, ectopic pregnancy which is
terminated and spontaneous termination of
pregnancy which occurs during a period of
gestation in which a viable birth is not possible.
False labor, occasional spotting, Physician
prescribed rest, morning sickness, hyperemesis
gravidarum, preeclampsia and conditions
associated with a difficult pregnancy are not
Complications of Pregnancy.
13. Custodial Care: Care comprised of services
and supplies which are provided to assist in the
activities of daily living for a Member who is
mentally or physically Disabled.
14. Deductible: The amount of payment required to
be paid by the Member before the Plan will
begin to provide benefits. For example, the
Calendar Year Deductible for Major Medical
Benefits is $250. Not all Covered Services
require a Deductible.
10. Copay: The amount of payment indicated in the
schedule of benefits that is due and payable by
the Member to the provider of services at the
time the services are rendered, or the percent of
charge based on the major medical benefit that is
the Member’s responsibility.
15. Dependent Coverage: Coverage for an Eligible
Dependent when the Employee has made
Application and payment of the required
Employee Contribution.
16. Disability or Disabled: A total incapacitation
resulting from an Illness or Injury which occurs
while the individual is covered under this Plan
and results in the complete inability of an
Employee to perform any and every duty
pertaining to any occupation, or the complete
inability of a dependent child to perform the
activities of daily living of a person of like age
and sex.
11. Cosmetic: Any service, expense or surgical
procedure that primarily improves or changes
appearance and does not primarily improve
physical bodily functions or correct deformities
resulting from disease, Injury or congenital
anomalies. Improvement of physical bodily
function does not include improvement of
psychological effects caused by physical defects
or conditions. The exclusion of Cosmetic
treatment does not include Reconstructive
Surgery. In some circumstances, a surgical
procedure may not be considered Cosmetic, or a
portion of a surgery would be covered as
Medically Necessary Reconstructive Surgery.
You and your Physician must contact the Claims
Administrator prior to any treatment for
determination of whether a procedure will be
treated as Cosmetic or Reconstructive.
17. Durable Medical Equipment: To be Durable
Medical Equipment, an item must at a minimum
be: (1) made to withstand repeated use; (2)
mainly for a medical purpose rather than for
comfort or convenience; (3) useful only if the
Member is sick or injured; (4) ordered and
prescribed by a Physician for use in the
Member’s home; and (5) directly related to the
patient’s physical disorder. The Plan will
consider the equipment as a Covered Service
only when the item in question is the least costly
available to provide treatment (for example, a
manually operated wheelchair rather than a
motorized wheelchair). Durable Medical
Equipment must be Pre-Certified by the Claims
Administrator and must be provided by a Blue
Cross and Blue Shield Provider.
57
23. Employee Contribution: The amount required
to be paid by the Employee, Surviving
Dependent or COBRA participant for single
and/or Dependent Coverage. Only Members for
whom the required contribution, applicable
funding rate or COBRA premium is received by
the Employer (or Claims Administrator when
required) shall be entitled to eligibility under the
Plan. All rights of the Member under the Plan
shall terminate as of the last day of the month
for which the required payment has been
properly received.
18. Effective Date: The date the Employee and/or
Eligible Dependent becomes covered under the
Plan based on the eligibility rules and acceptance
and approval of the written Application by the
Human Resources Department. Verification of
the Effective Date is made through issuance of
an identification card or other written
notification.
Payment of the Employee
Contribution is not evidence or verification of
the Effective Date.
19. Eligible Dependent: Includes only a person
listed on the Application and accepted by the
Human Resources Department, who is the
Eligible Employee’s: (1) lawful spouse of the
opposite sex; (2) unmarried child under age 19;
(3) unmarried child under age 25 while a FullTime Student; (4) unmarried Disabled child of
any age, provided the Disability commenced
prior to age 19; the child was enrolled under the
Plan prior to age 19 and coverage continues
without interruption for the duration of the
Disability. The Employee is required to provide
information to verify dependent status within 30
days of a request for verification from the
Human Resources Department or Claims
Administrator. Failure to provide timely proof
of dependency, when requested, will result in
termination of the dependent’s coverage.
24. Employer: The University of South Alabama.
25. Employer Contribution:
The Employer
Contribution is that amount paid by the
Employer on behalf of the Members. No
Member, beneficiary or third party shall have
any right, title or interest in the Employer
Contribution or any part thereof except as
provided in the form of benefits through the
USA Health Plan.
26. Experimental or Investigative: Any treatment,
procedure, facility, equipment, drugs, drug
usage, or supplies either not recognized by the
Claims Administrator as having scientifically
established medical value or not in accordance
with generally accepted standards of medical
practice. Covered Services include only
technology or treatment which meet all of the
following criteria: (1) have final approval from
the appropriate governmental regulatory bodies
for the specific use for which it is intended; (2)
permit conclusions concerning the effect on
health outcomes; (3) improve net health; (4) be
as beneficial as any established alternatives; (5)
be classified and approved by the Health Care
Financing Administration (Centers for Medicare
and Medicaid Services) (Medicare) for its
intended use; and (6) be classified and approved
by the Claims Administrator.
20. Eligible Employee: An Employee who has
made timely Application to the Human
Resources Department for coverage and proper
authorization for payroll deduction of the
Employee Contribution, and has had such
Application approved and acknowledged
through the issuance of an identification card or
some other written notification of coverage.
21. Emergency Admission: An admission to a
Hospital, made through the emergency
department of the Hospital, when the Member
requires immediate medical intervention as a
result of a severe, life threatening or potentially
disabling condition (a type 1 emergency as
defined in the manual of the Health Care
Financing Administration (Centers for Medicare
and Medicaid Services)).
27. Extended Care Facility: A Medicare-approved
facility providing non-acute care for patients
requiring 24-hour nursing services. An Extended
Care Facility: (1) is engaged in providing skilled
care under the supervision of Physicians and
registered nurses; (2) maintains clinical records
on all patients; (3) provides 24-hour nursing
services; and (4) provides appropriate
procedures for dispensing and administering
drugs and is duly licensed. Facilities for
custodial, domiciliary care, Mental Health or
Substance Abuse treatment are not covered.
22. Employee: A regular University of South
Alabama employee who has a specific
appointment with no termination date, who
occupies a permanently budgeted University
position, and works a minimum of 20 hours per
week on a regular basis.
58
32. Hospital: A facility licensed as a hospital,
operated for the care and treatment of resident
inpatients, which has a laboratory, registered
graduate nurses always on duty and an operating
room where major surgical operations are
performed. In no event shall the term hospital
include an institution or that part of an
institution which is used principally as a clinic,
convalescent home, rest home, nursing home or
home for the aged, drug addicts or alcoholics.
28. Family and Medical Leave Act (FMLA): The
Family and Medical Leave Act of 1993, as
amended, which requires that employers who
offer group health coverage to their employees
continue to make that coverage available while
an Eligible Employee is on qualified leave.
29. Full-Time Student: One who is enrolled and
physically attending on a full-time basis a state
accredited high school, trade school, college or
university.
This does not include any
correspondence course, home learning program
or educational institution that is not properly
accredited. Full-Time is considered to be no less
than 12 semester or quarter hours. An individual
cannot take off more than one academic session
in an academic year and remain an Eligible
Dependent. The Plan reserves the right to
retroactively terminate coverage when the
dependent is no longer a Full-Time Student or if
proper evidence of Full-Time Student status is
not submitted by the Member when requested.
33. Illness: A disease, disorder or condition that
requires treatment by a Physician, occurring
while the Member is covered under the Plan.
34. Injury: A traumatic injury requiring immediate
medical attention, caused solely by accident and
occurring while the Member is covered under
the Plan.
35. Lifetime Maximum Benefit: The maximum
liability for all Covered Services incurred by a
Member is $1,000,000. The Lifetime Maximum
Benefit applies even when coverage is
interrupted, or when a Member is covered at one
time as an Eligible Dependent and at another
time as an Employee. Lifetime Maximum
Benefit limitations also apply to some specific
Covered Services.
30. Generic Drug: One that has been approved by
the Food and Drug Administration as
therapeutically equivalent to the original “name
brand” drug. The FDA approves the generic
equivalent as interchangeable with the brandname drug under all approved indications and
conditions for use. The lowest Copay applies to
generic drugs under the Prescription benefit.
36. Maximum Benefit: The maximum liability for
Covered Services incurred by a Member while
covered under the Plan, as stated in the schedule
of benefits. These maximums may be dollar
amounts, limits on number of days covered,
limits on number of visits or treatment sessions
allowed for coverage, or age limits on coverage,
and apply to the entire time a Member is covered
under the Plan even if coverage is interrupted.
31. Hospice Care: Care provided by an agency or
organization which: (1) provides hospice care;
(2) is licensed or certified; and (3) meets the
standards established by the National Hospice
Organization. Hospice Care is a coordinated,
interdisciplinary program to meet the physical,
psychological and social needs of Terminally Ill
persons by providing palliative and supportive
medical, nursing and other health services
through home or inpatient care.
37. Medical Emergency: An Injury or a sudden
unexpected onset of an Illness which requires
immediate diagnosis or medical or surgical
treatment. This condition must require that the
Member seek immediate medical attention from
the nearest available facility, and which if not
performed without delay would jeopardize or
impair the Member’s life or health (a type 1
emergency or type 2 urgent care condition as
defined in the manual of the Health Care
Financing Administration [Centers for Medicare
and Medicaid Services]) Use of an emergency
room for treatment that is not a Medical
Emergency, as determined by the Claims
Administrator, will be paid according to the
Major Medical benefits schedule, at 80% subject
to the $250 Calendar Year Deductible.
Hospice Care may include short-term inpatient
hospital stays required for the Terminally Ill
person in order to give temporary relief to a
caregiver who regularly assists with home care
(limited to five days during any 90 day period).
Caregiver means only a person not associated
with the hospice agency who resides in the home
and provides non-medical services and
companionship, including a family member.
Hospice Care services are limited under the
Home Health Care - Benefit Limitation and must
be Pre-Certified.
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43. Non-Preferred Brand Name Prescription: A
brand-name drug that has not been identified by
the Claims Administrator as a Preferred Brand
Name Prescription. Under the Prescription Drug
Card benefit of this Plan, Non-Preferred Brand
Name drugs are dispensed at a higher Copay. In
instances in which a Physician indicates a
specific Non-Preferred drug is needed by the
Member, or the Member chooses a brand-name
drug that has a Generic equivalent, these
prescriptions are considered Non-Preferred, and
the highest Copay will apply.
38. Medical Necessity or Medically Necessary:
Benefits are provided only for services and
supplies determined by the Claims Administrator
to be Medically Necessary.
To be Medically Necessary the service or
supplies must at a minimum be: (1) consistent
with the diagnosis and treatment of your
condition; (2) in accordance with standards of
good medical practice and generally recognized
professional standards; (3) approved for
reimbursement by the Health Care Financing
Administration (Centers for Medicare and
Medicaid Services) (Medicare); (4) performed in
the least costly setting required by your
condition; (5) not primarily for the convenience
of you or your Physician; and (6) not
Experimental or Investigative. Evidence to help
determine whether the services are Medically
Necessary may be required before benefits are
provided.
44. Open Enrollment Period: The one-month
period, usually the month of November, during
which Employees may enroll in the Plan and/or
add Eligible Dependents for coverage beginning
the first of the following Calendar Year. During
this period Eligible Employees may terminate
coverage for one or more dependents. This is
also the period during which Eligible Employees
enroll or terminate participation in the Section
125 Premium Conversion Plan.
39. Medicare: Title XVIII of the Social Security
Act, as amended, titled the Health Insurance for
the Aged Act, which provides health benefits to
participants based on age or disability.
45. Out-of-Network: A term used to describe
services received from health care providers
who are not Blue Cross and Blue Shield PPO
Providers. In many instances, benefits are not
provided for services received Out-of-Network.
40. Member: An Eligible Employee or Eligible
Dependent based on the established eligibility
provisions and payment of the required
contribution, for whom Application has been
accepted by the Human Resources Department.
46. Physician: One of the following when duly
licensed and acting within the scope of that
license: Doctor of Medicine (MD), Doctor of
Osteopathy (DO), Doctor of Dental Surgery
(DDS), Doctor of Medical Dentistry (DMD),
Doctor of Chiropractic (DC), Doctor of Podiatry
(DPM), Doctor of Optometry (OD), Registered
Nurse Practitioners, Certified Nurse Midwives,
and Psychologists (PhD, PsyD, EdD), as defined
in Section 27-1-18 of the Alabama Code, 1975,
as amended. The term Physician also includes a
licensed physician assistant (PA) or surgeon
assistant (SA) when: (1) employed by and acting
under the direct supervision of a Blue Cross and
Blue Shield Provider M.D.; (2) acting within the
scope of his or her license and in compliance
with local law; and, (3) the services of the PA or
SA would have been covered if provided
directly by the MD.
41. Member Handbook: This written description
of the benefit plan in an easy-to-read format,
including eligibility, benefits, employee rights
and responsibilities, and appeals procedure. It
also includes any changes to the Plan effective
after January 1, 2006 issued as an addendum.
The USA Health Plan Management Committee
reserves the right to interpret the Plan, to amend
or change the Plan, terminate any or all benefits
and to make final determinations with regard to
all matters concerning the Plan.
42. Mental Health Treatment: Treatment for a
mental condition which includes (whether
organic or non-organic, of biological, nonbiological, genetic, chemical or non-chemical
origin, irrespective of cause, basis or
inducement) a mental disorder, mental Illness,
psychiatric Illness, nervous condition, neurotic
disorder, schizophrenic disorder, affective
disorder, personality disorder, psychological or
behavioral abnormalities associated with
transient or permanent dysfunction of the brain
or related neurohormonal systems.
47. Plan: The USA Health Plan as described in this
Member Handbook.
60
54. Special Enrollment Period: The 30-day period
following a Change-In-Status Event that allows
an Employee to enroll in the Plan and/or add
Eligible Dependents, or terminate coverage for
one or more dependents, without having to wait
for the Open Enrollment Period. The Special
Enrollment Period also applies to Change-InStatus Events that allow participants to change
their election under the Section 125 Premium
Conversion Plan.
48. Pre-Certification: The administrative procedure
whereby the Member or Physician is required to
submit information or a treatment plan to the
Claims Administrator before the treatment or
expense is initiated. The Claims Administrator
reviews the treatment plan for approval before
those services or expenses are considered
eligible for reimbursement under the Plan.
49. Pre-Existing Condition: Pre-Existing Conditions
include pregnancy or any disease, disorder or
ailment, congenital or otherwise, which existed
on or before the Effective Date of coverage,
whether or not it was manifested or known in
any way, or any condition diagnosed or treated
in the 12 months before the Effective Date.
55. Substance Abuse Treatment: Treatment for a
chronic disorder or Illness in which the Member
is unable, for psychological or physical reasons,
or both, to refrain from the frequent
consumption of alcohol, drugs, intoxicants or
narcotics in quantities sufficient to produce
intoxication or overdose and, ultimately, injury
to health and effective functioning.
50. Preferred Brand Name Prescription: A brand
name drug identified by the Claims
Administrator as both effective and costefficient, and eligible for a lower Copay by the
Member.
56. Terminally Ill: A patient who is determined by
a Physician to have a terminal Illness with no
reasonable prospect of cure and who is expected
by a Physician to have less than six months to
live.
51. Pregnancy: The condition of and complications
arising from a woman having a fertilized ovum,
embryo or fetus in her body, usually but not
always in the uterus, lasting from the time of
conception to the time of childbirth, abortion,
miscarriage or other termination.
57. Uniformed Services Employment and
Reemployment
Rights
Act
of
1994
(USERRA):
Public Law 103-353, which
requires that employers who offer group health
coverage to their employees continue to make
that coverage available while an Eligible
Employee is on duty, voluntarily or involuntary,
in the Uniformed Services.
52. Qualified Medical Child Support Order
(QMCSO): A QMCSO is a judgment, decree or
order issued by a court of competent jurisdiction
that requires the USA Health & Dental Plan to
enroll dependents named in the order under the
Plan. A medical support order must be filed
with the Human Resources Department within
30 days of the date of the order and must meet
certain criteria, as explained in this Member
Handbook, to be considered a QMCSO.
58. USA Health Plan Management Committee:
Those persons charged with the responsibility
and authority for management of the USA
Health Plan as authorized in the Plan document.
59. USA Health System Provider: Providers
affiliated with the University of South Alabama.
Their participation allows the Plan to provide
benefits at a lower cost to the Member. USA
Health System Providers are an important part of
the Plan.
53. Reconstructive: Reconstructive procedures are
Covered Services under the Plan when: (1)
determined to be Medically Necessary; (2)
intended to primarily improve or restore physical
bodily function or correct deformities resulting
from Illness, Injury or congenital anomalies; and,
(3) do not serve primarily to improve or change
appearance. In some circumstances, a surgical
procedure may be considered Reconstructive, or a
portion of a Cosmetic surgery would be covered
as Medically Necessary Reconstructive Surgery.
You and your Physician must contact the Claims
Administrator prior to treatment for determination
of whether a procedure will be treated as
Cosmetic or Reconstructive.
61