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Email: claims@usablelife.com

Accident Care

Living an active life is everyone’s expectation. But an accident can change everything in the blink of an eye. The costs of dealing with a life-altering accident can be overwhelming for those who are unprepared. After an accident, bills can mount quickly and linger for years, leaving a lasting effect on everyone in the household.

Because Accidents Happen! Accident Recovery offers an additional layer of financial protection for you and your family. This plan pays YOU directly in the event of a covered accident.

Group Number for St. Bernards Clincs is 50042523

Accident Recovery Based on 24 Payroll Deductions Per Year

USAble Customer Service

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Email: claims@usablelife.com

Hospital Care

You have the option to purchase Hospital Care coverage through USAble. You have two plan options to choose from and you can elect coverage for yourself, your spouse, and your children. This coverage pays a benefit directly to you when you are admitted to the hospital for a covered stay.

While we have great medical benefits under the health plan, this coverage complements your health insurance to help you pay for the costs associated with a hospital stay. It can also provide funds which can be used to help pay the out-of-pocket expenses your medical plan may not cover, such as coinsurance, copays, and deductibles. Evidence of Insurability (EOI) is never required when enrolling in the Hospital Care plan.

Group Number for St. Bernards Clincs is 50042523

Hospital Claim Form

Life Claim Form

USABLE Website

USAble Customer Service

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Email: claims@usablelife.com

Critical Care

Every few seconds, an American suffers a heart attack or learns that he or she has cancer. The impact on their family’s finances can be devastating. The copays and the expenses that aren’t covered by major medical insurance eat away at savings as well as the belief that things can get better.

Group Number for St. Bernards Clincs is 50042523

Accident Recovery Based on 24 Payroll Deductions Per Year

USAble Customer Service

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Evidence of Insurability Form

Email: claims@usablelife.com

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Life and Accidental Death and Dismemberment (AD&D)

Employee Supplemental Life and AD&D—Optional

Newly hired employees are eligible to purchase additional life insurance in increments of $10,000 up to a maximum benefit of 5 times your annual salary or $200,000. At age 65, the original benefit is reduced to 65%. At age 70, the original benefit is reduced to 50%. The same coverage options exist for supplemental AD&D coverage.

You may select up to $200,000 without submitting evidence of insurability (EOI), also known as proof of good health. If you are a late entrant you may enroll during open enrollment in the amount of $10,000. Currently enrolled employees can increase their coverage option by $10,000 during enrollment up to the guarantee issue amount. Refer to page 13 for more information about EOI.

If you elect over the GI values (200k for Employee, 30k for Spouse) you will be prompted to complete Evidence of Insurability. If proof of good health is not provided, your elected coverage amounts will be denied.

Cost for Employee Supplemental Life and AD&D Coverage

Life Claim Form

Worksite Benefits ( Accident, Critical or Hospital Care Forms)

Beneficiary Form

Online Access

You can also complete the USAble Forms online. The online option is for submitting only. There is not an online option to check the status of the claim. Group Number for St. Bernards Clinics is 50042523, this is required to submit a leave online.

Click Here to Submit Forms Online

USAble Life Contact Information

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Email: claims@usablelife.com

Short Term Disability

If you have FMLA, do not use these forms. Go to the Family Medical Leave page from the Home screen for the correct forms.

Short term disability (STD) insurance helps provide financial security while you are on an approved medical leave. You will receive a weekly benefit in $50 increments (minimum of $100) up to $1,000, not to exceed 70% of your pre-disability base pay for up to 25 weeks. There is a 7 calendar-day elimination period and benefits are paid out on the 8th day.

Additional Plan Details—Optional

Contributions are based on the benefit selected amount
Your PTO is concurrent with the STD benefit
Disability must be approved by USAble Life
Pre-existing conditions are waived if enrolling during your initial eligibility period
Benefit reduction and termination:
- At age 65, the original benefit is reduced to 66⅔%
- Terminates at age 70

Short Term Rate Chart

STD Form Process

Employee Statement - employee can submit by the form below or online
Physician Statement - employee will take the form below to the physician
Employer Statement - employee will email HR at HR@sbrmc.org once the employee statement and the physician statement have been completed. HR will then complete the employer statement for the leave.

Short Term Disability Paper Form

It is the employee's responsibility to make sure all 3 statements are submitted to USAble Life.

Online Access

You can also complete the USAble Forms online. The online option is for submitting only. There is not an online option to check the status of the claim. Group Number for St. Bernards Clinics is 50042523, this is required to submit a leave online.

Click Here to Submit Forms Online

USAble Life Contact Information

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Long Term Disability Paper Form

Email: claims@usablelife.com

Long Term Disability

Long Term Disability (LTD) replaces a portion of your income due to a non-work related disabling illness or accident for an extended recovery period.

Basic Long Term Disability is a Company Paid Benefit

$8,000 maximum per month benefit when combined with Basic LTD

Benefits continue to age 65 or later depending upon your age at the

date of disability

Provides up to 40% of base pay for full-time employees. You are automatically enrolled in the Basic LTD plan
180-day elimination period
$6,000 maximum per month benefit
Two years for your own occupation; after that, any occupation
Benefits continue to age 65 or later depending upon your age at the date of disability
Pre-existing conditions apply

OPTION 1

Adding employee paid 10% to the 40% company paid benefit for a total of 50%.
Monthly benefit payout on a salary of $30,000 x 40% (company paid portion) = $1,000 per month.
The $30,000 x 50% (40% company paid + 10% employee paid) = $1,250 per month.

OPTION 2

Adding employee paid 20% to the 40% company paid benefit for a total of 60%.
Monthly benefit payout on a salary of $30,000 x 40% (company paid portion) = $1,000 per month.
The $30,000 x 60% (40% company paid + 20% employee paid) = $1,500 per month.

Long Term Online Form

Online Access

You can also complete the USAble Forms online. The online option is for submitting only. There is not an online option to check the status of the claim. Group Number for St. Bernards Clincs is 50042523, this is required to submit a leave online.

Click Here for online instructions

Click Here to Submit Forms Online

USAble Life Contact Information

Toll free: (800) 370-5856

Monday - Friday 8 a.m. - 5 p.m. (CST)

Dependent Care Fact Sheet

DataPath Flexible Spending for Health Care

DataPath offers an FSA debit card, which allows you to pay for eligible expenses directly from your account. Expenses include medical, prescription, dental and vision. The advantage of using the FSA for these expenses is that you get all of your money at the beginning of each year and is tax free. If you choose to participate, you may contribute up to $2,750 per year on a pre-tax basis. Money is loaded to your card on 1/1 and you split up the contributions through out the year pre-tax.

Receipt Rules

The below list shows transactions that do not require you to submit an itemized receipt:

St. Bernard’s Affiliated pharmacies & clinic’s.
- Jonesboro Plastic Surgery & McClurkan Clinic are excluded & require receipts.
Amounts that match the co-pays attached to your health or dental benefits.
Pharmacies with the IIAS certification. This is an inventory system that approves or denies items at the point of sale. Typically larger locations such as Kroger or Wal-Mart have this in place at their pharmacy counters.

ALL OTHER LOCATIONS OR OUTSIDE THE COPAYS WILL REQUIRE A RECEIPT. This is NOT a debit card receipt.

Per IRS guidelines, if you use your card outside of the set paramaters you are required to submit an itemized receipt to substanitate the transaction. All transactions are subject to review. Failure to do so will result in the funds being owed back to the plan.

Itemized Recipts must contain:
- Date of Service
- Service Performed
- Patient Name
- Amount

If you are uncertain if an item is covered you can contact customer service for further asssitance at 1-877-685-0655.

FSA Funds Notice

FSA is a use it or lose it program.

All transactions must be for the dates of the service year from 1/1 to 12/31.
- This is not when you receive a bill but when the service date was compelted.
All FSA claims must be submitted to DataPath on or before 3/31 for dates of service from the prior year.
Any funds left after your run out period will be forfeited.

Account Setup

You will receive in the mail a series of plan white envelops with your FSA account setup. These are sent separately for your protection.

To activate your card by phone, use the TPA number 10.

To register online, use the Employer ID 10307 and the Participant ID that came in the mail with your card. If you do not know your Participant ID contact Human Resources or call DataPath Customer Service.

Enrollment Guide

Login Instructions

Claim Reimbursement Form

Direct Deposit Form

FSA Store

DataPath Website Click Here

Customer Service 1-877-685-0655

Email: St.bernards@datapathadmin.com

Mobile Summit App

Dependent Flexible Spending Account

DataPath offers an FSA debit card, which allows you to pay for dependent expenses directly from your account. The advantage of using the FSA for these expenses is that you get all of your money at the begining of each year and is tax free. If you choose to participate, you may contribute up to $5,000 per year on a pre-tax basis ($2.500 maximum if married and filling separate tax returns.)

Eligible dependent care expenses include:

Before- and after-school care
Extended day programs
Daycare, preschool, or nursery school
Summer day camp
Elder day care

An eligible dependent is:

A child under age 13, who is claimed as a dependent on your income tax
A child age 13 and older, who depends on you for at least half of his/her support;
Regularly spends at least eight hours a day in your household; and
Is physically or mentally unable to care for himself/herself
A disabled spouse
An elderly parent

Instructions

Dependent Care requires a request reimbursement from you on your Dependent Care Account. Contributions will be reimbursed to you on a per pay period basis. Deductions go out of your pay check on payroll Thursdays and deposit into your bank account on Friday. You must complete the Direct Deposit Form and the Recurring Expense Form below. By completing the Recurring Expense Form you will not need to provide continuing documentation for the remainder of the plan year.

Please note: forms should be completed at the beginning of the plan year. the sooner you submit the required forms, the sooner you will see a reimbursement payment in your bank account on Friday.

Enrollment Guide

Recurring Expense Form

Direct Deposit Form

DataPath Website Click Here

Customer Service 1-877-685-0655

Email: St.bernards@datapathadmin.com

Mobile Summit App

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Superior Vision by DeltaDental

Our Delta Vision plan is offered through Delta Dental of Arkansas. Register online to search for providers, print claim forms, print ID cards, check claim status, and view covered members.

REGISTER ONLINE

Finding In-Network Providers
Remember to visit in-network providers to receive the deepest level of discount on your services. To find a participating in-network provider in your area go online or call 844.549.2603.

VIEW CERTIFICATE OF COVERAGE

DOWNLOAD VISION CLAIM FORM

Dental by BlueAdvantage

Dental insurance is offered through BlueAdvantage Administrators of Arkansas.

Finding In-Network Providers
Remember to visit in-network dentists to receive the deepest level of discount on your services. To find a participating in-network dentist in your area go online or call 888.223.4999.

Register with My Blue Print
Register with My Blue Print to order replacement cards, check claims status, review EOB’s, check deductibles, and review your personal health record.

REGISTER ONLINE

IN-NETWORK PROVIDER LINK

Clinic Dental Rates Per Pay Period

Employee Only $0.00 (Paid by Company)
Family $30.52

DENTAL CLAIM FORM

Paragould Dental by Delta Dental

Dental insurance is offered through Delta Dental of Arkansas.

Finding In-Network Providers
Remember to visit in-network dentists to receive the deepest level of discount on your services.

Register with My Blue Print
Register to order replacement cards, check claims status, review EOB’s, check deductibles, and review your personal health record.

REGISTER ONLINE

IN-NETWORK PROVIDER LINK

Dental Rates Per Pay Period

Employee Only is $0.00 (Paid by Company)
Family is $31.65

DENTAL CLAIM FORM

DENTAL PLAN DOCUMENT

Medical Plan

For Regular Full-time Employees. This plan does not include Staff Support Employees.

SHARP (St. Bernards Healthcare Associated Regional Providers, Inc.) is a physician hospital organization (PHO) developed in 1994 by St. Bernards Healthcare and the physicians in Northeast Arkansas. SHARP connects providers, employers, and patients seeking medical services to create the very best healthcare service possible at an affordable rate. With over 4,300 providers and 173 facilities, SHARP is one of only a few PHOs in the country that is licensed to provide services to review the necessity, use, appropriateness, and efficiency of healthcare services. Utilization review is about verifying value for the healthcare consumer.

SHARP provides St. Bernards Medical Center employees the following services to help reduce healthcare costs.

We partner with BlueAdvantage Administrators and SHARP to offer medical coverage for the St. Bernards Health Plan.

BlueAdvantage Administrators can provide you with all information as it relates to what your health plan will cover, benefit limits, claims processing and explanation of benefits (EOBs). For medical claims call 800-370-5853 and for prescription claims call 888.293.3748.

SHARP can provide you with our in-network providers. They also are able to case manage on some physicians that are out-of-network.

Network Coverage:

SHARP Identifies In-Network Providers—contact SHARP for local and surrounding areas in-network providers and facilities.
Referrals outside SHARP Network—Must have prior authorization from referring physician to SHARP prior to services rendered. Specialists visits outside of the SHARP network must be referred from the current treating Specialist in-network.
To find a SHARP provider or facility in-network, go to https://www.stbernards.info/sharp-pho Or call 870-972-0032
Precertification*: SHARP provides precertification services as required by the plan for all Inpatient Services, Outpatient Surgery (excluding EGD, Colonoscopy, and HC), CT, MRI, PET Scans, insulin pumps (prior authorization required), and private duty nursing services.

Employees must get approval for out-of-network coverage and precertifications or penalties could be applied.

Find In-Network Providers Here

* This True Blue PPO is essentially a "wrap" network to the SHARP PHO network. If SHARP pre-approves and refers a member to one of the True Blue PPO providers (Tier 2), then the claim would be paid at 80% after the deductible is met. If SHARP does not pre-approve using a provider outside of the SHARP network, it is subject to only being paid at 25% after the deductible is met. Care provided by an out-of-network facility in the event of an emergency is processed as an in-network claim. See plan documents for specifics.

Network Deductibles and Cost

Click on the flyer below for more information!

No ID Card? No Problem!

With My Blueprint Mobile, you can view, print, email, or fax your ID card while in your doctor’s office. You can also access many more My Blueprint features such as order replacement cards, check claims status, review EOB’s, check deductibles, and review your personal health record.. Click on the flyer below for more information!

What does your plan cover?

The purpose of a Coverage Policy is to inform members and their physicians why certain medical procedures may or may not be covered under Arkansas Blue Cross and Blue Shield health plans. In addition to these specific Coverage Policies, all Arkansas Blue Cross and Blue Shield health plans or contracts also include more generally applicable coverage standards known or the Primary Coverage Criteria. The Primary Coverage Criteria apply to ALL benefits members may claim under their plan, no matter what types of health intervention may be involved or when or where members obtain the intervention. For more specifics on Primary Coverage Criteria, click on the Primary Coverage Criteria link here.

Covering Dependents

Dependents for coverage generally include Legal Spouse and Children. All dependents must have the required documents submitted prior to the benefit start date or they will be dropped from your coverage. More information can be found in the Covering Your Family Link here.

Do you need help navigating through the medical plan?

Your Employee Care Navigator is an RN Case Manager available to assist you with healthcare needs. The program is designed to help employees and their dependents get from place-to-place in a healthcare system that can often be difficult to understand. Your personal health information will always remain confidential. Give Beth Wallace a call to help you with any of your health care needs. Beth serves as a patient representative to facilitate medical care and navigate the healthcare system including coverage through BlueAdvantage and SHARP.

Beth Wallace, RN 870-207-7486 or 870-351-6831 or e-mail at owallace@sbrmc.org

Other Medical Forms

Contact Information

BlueAdvantage Administrators

Phone Number: 800-370-5853

Website: www.blueadvantagearkansas.com

Email: BAACustomerService@arkbluecross.com

SHARP for Network and Precertification Questions

Phone Number: 870-972-0032

Website: https://www.stbernards.info/sharp-pho

Care Navigator, Patient Representative for Employees to help with SHARP and BlueCross

Beth Wallace, RN 8

870-207-7486 or 870-351-6831

Email: owallace@sbrmc.org

Human Resources for Payroll Deductions and Qualified Insurance Changes

Shannon Hamrick

870-207-1604

Email: smhamrick@sbrmc.org

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Prescription Plan

Formulary

St. Bernards uses the Standard with Step Therapy Formulary (list of drugs covered by tier) which follows a step therapy approach. Members are required to purchase a generic drug before a brand-name drug is covered. If a member hasn’t used the generic option in 24 months, or the member’s physician does not submit a request for approval to get brand without having the Step, the member is required to try generic or the name brand drug will be considered a 100% member pay drug. Please keep in mind you have access to the Employee Pharmacy which could save you money.

USABLE DRUG FORMULARY

Immunizations

Medical plan members can utilize pharmacies for vaccinations. Certain vaccinations, as provided by the Affordable Care Act, are 100% covered using the prescription drug benefit. This includes all the preventive routine vaccinations but does not apply to travel related vaccinations. The shingles vaccine is now covered at 100% administered at a pharmacy.

Zero Cost Immunizations

Preventive Serivces

What is a Qualifying Life Event?

A qualifying life event (QLE) is an event deemed acceptable by the IRS that may allow participants in section 125 plans to change their benefit elections. You may change your benefit elections during the annual Open Enrollment period or during the year if you experience a Qualifying Life Event. A Life Event change permits employees to make certain mid-year benefit changes consistent with the qualifying event. You must consult your Benefits Administrator within 31 days from the date of the event to make changes.

Qualifying Life Events

Special Enrollment Rights: An event described in the Special Enrollment provisions as shown in the group policy/plan;
Entitlement to or loss of eligibility for Medicare or Medicaid: The employee or the employee's dependent becomes entitled to or loses eligibility for Medicare (Part A or Part B) or Medicaid.
Special Requirements relating to the Family and Medical Leave Act (FMLA): An employee takes leave under FMLA, in which case the employee may revoke an existing election of health plan coverage and make such other election for the remaining portion of the period of coverage as may be provided for under FMLA.
Significant cost or coverage changes: Cost of coverage changes significantly.
A judgment, decree or order: Resulting from a divorce, legal separation, annulment, or change in legal custody (including a qualified child support order) that requires health coverage for an employee's dependent child or for a foster child who is a dependent of the employee.

Changes in status events, which include the following:

Legal marital status: Change in the employee's legal marital status, including marriage, death of spouse, divorce, legal separation and annulment;
Number of dependents: Change in the employee's number of dependents, including birth, death, adoption and placement for adoption.
Employment status: Change in the employment status of the employee or the employee's dependent, including termination or commencement of employment, a strike or lockout, a commencement of or return from an unpaid leave of absence or a change in worksite. This also includes a change in the employee's or the employee's dependent's employment status resulting in the individual becoming or ceasing to be eligible under the group policy/plan;
Eligible dependent status: Change in the eligibility of a dependent due to reaching a limiting age, change in student status or any similar circumstance; and
Residence: Change in the place of residence of the employee or the employee's dependent provided that the change in place of residence affects the eligibility for the employee or the employee's dependent's coverage under the group policy/plan.

Consistency Rule: In all cases, any election change as a result of any change in status must be on account of and correspond with a change in status that affects eligibility for coverage under the plan. For example, if the change in status is the employee's divorce, the death of a spouse, an employee's election to cancel health coverage will apply only to the spouse involved.

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Marriage

Once you are married, you may add your spouse to your existing medical, dental, vision or hospital coverage, enroll in a medical plan, change to another option or drop your coverage to go on your spouse’s plan. You will need to complete the appropriate forms and provide a copy of your certified marriage certificate along with a copy of the spouse driver's license. You should also review your beneficiary designations for life insurance, retirement savings, and pension plans. You must consult the HR Department within 31 days from the date of the event to make changes.

How To Make Benefit Changes Online

Use the Life Event Instruction link below to create a Life Change Event in the enrollment portal to make changes to benefits. Be sure to upload the required documents to make the change.

Eligible changes include:

Medical
Dental
Vision
Hospital Care
Beneficiaries for Life Insurance

Required Documents:

Provide Marriage License
Provide Spouse Driver's License

Review/Change Beneficiaries and Emergency Contact Information:

If you need access to see what benefits you currently have, click on Enrollment Portal link below. Log in the same as you did during open enrollment. If you do not know your password, use the forgot password option. From here, you can change beneficiaries and emergency contact information.

OR Change By Paper Form and send to Human Resources

Retirement Beneficiary Changes

This is also a good time to change your beneficiaries in your retirement. If you are currenly in the TIAA retirement plan, use the link below to log into your account to make the beneficiary changes. If you are in the Pension plan, complete the form below and return to Human Resources.

Tax Forms

To change your tax withholdings, complete the forms below and return to Human Resources. Changes are made on the next payroll.

Social Security Card Application Link

Name Change

For a name change, complete the change form from the link below. A copy of your Social Security Card with the new name is required. You can either bring it into Human Resources or email to HR@sbrmc.org.

Name Change Link

For the Social Security Administration

If you legally change your name because you get married, you will need to apply for a corrected Social Security card with your changed name. Failure to do so could delay a tax refund coming to you or prevent some of your pay from being credited properly to your Social Security record, which could cause your future Social Security benefits to be less than they should be. You will need to provide a recently issued document, such as your marriage license/certificate, as proof of your legal name change. If the document you provide does not give the Social Security Administration enough information to identify you in its records, you will be asked for an identity document showing your old name and another in your new name providing evidence of your identity. You will need to fill out an Application for a Social Security Card (SS-5) form and submit it to the Social Security Administration. You can download a copy of the SS-5 form and instructions in an electronic format from here and print it out at your leisure. The instructions include details on acceptable evidence of your identity. Also, you can visit the Social Security website or call 1-800-772-1213.

Baby/Adoption

This material will provide you with resources that can guide you toward your life goal--to bring your new child into your family and nurture the happiness and well-being of a precious child.

Have you started your FMLA Leave?

What is the Family Medical Leave Act (FMLA)? FMLA is a federal law that entitles employees to 12 weeks of unpaid leave for qualifying medical and family reasons. This time can be used over the course of 12 months for qualifying medical and family reasons. Go online to FMLASource to start a leave case or call 877-GO2-FMLA. This can be done for the mother and/or the father. Be sure to let FMLASource know your return date to work. A Fit for Duty must be submitted to FMLASource 1 week prior to returning. If you are unable to submit in advance, a copy should be given to your manager on your return date.

FMLA Instructions

FMLASource Website

When To Make Benefit Changes

After the birth or adoption (official placement or final decree), or court order, you may add the child to your existing medical, dental, or vision coverage, or drop your coverage to go on your spouse’s plan. You may elect to change your medical FSA amount and start or change a dependent care FSA. You may also elect child life insurance. You will need to complete the appropriate forms and provide a copy of the certified birth certificate, adoption placement order or decree, or court order. You must consult your HR Department within 31 days from the date of the event to make changes.

Note: Medicaid Health Insurance programs are offered during your stay at St. Bernards. These programs will offer assistance to those that qualify based on income and family size. If you complete an application for this program, it does not automatically enroll your child in your employee health insurance. If you have questions or concerns, please contact HR.

How To Make Benefit Changes Online

Use the Life Event Instruction link below to create a Life Change Event in the enrollment portal to make changes to benefits. Be sure to upload the required documents to make the change.

Eligible changes include:

Medical
Dental
Vision
Hospital Care
Beneficiaries for Life Insurance

Required Documents:

Provide birth certificate or birthing letter from the hospital
Provide Social Security Number

Review/Change Beneficiaries and Emergency Contact Information:

If you need access to see what benefits you currently have, click on Enrollment Portal link below. Log in the same as you did during open enrollment. If you do not know your password, use the forgot password option. From here, you can change beneficiaries and emergency contact information.

OR Change By Paper Form and send to Human Resources

Retirement Beneficiary Changes

This is also a good time to change your beneficiaries in your retirement. If you are currenly in the TIAA retirement plan, use the link below to log into your account to make the beneficiary changes. If you are in the Pension plan, complete the form below and return to Human Resources.

Insurance Payments

You may be required to pay for your insurance while out on leave. Once your PTO runs out, complete the form below and submit to Human Resources.

Insurance Payment Form

Tax Forms

To change your tax withholdings, complete the forms below and return to Human Resources. Changes are made on the next payroll.

Need a Pediatrician?

Click Here to find an in-network provider!

Short Term Disability And Other USABLE BENEFITS

For your convenience, Employee Assistance, Short Term Disability, Accident Care, Critical Care and Hospital Care will automatically be sent to you (if you have the benefit) when you create a leave case with FMLASource. It is up to you to decide which benefit applies to your leave.

Short Term Disability You will complete the Employee Statement and the physician will complete the Attending Physician Statement. Submit to USAble using the email, fax or address provided at the top of the claim forms. Payment for this benefit starts on the 8th day after your last day worked.
USAble Accident, Critical or Hospital Care You will complete the Employee Statement and the physician will complete the Attending Physician Statement. Submit to USAble using the email, fax or address provided at the top of the claim forms.
If you plan to add the baby to your Hospital Care benefit, complete a separate claim form for the baby. The Hospital Attending Physician’s Statement should be emailed to Brittney Martin at bdgoad1@sbrmc.org. Brittney will return the complete statement back to you so you can submit to USAble.

HOSPITAL CLAIM FORM LINK

EAP The St. Bernards Employee Assistance Program (EAP) has been designed to help employees and their families ﬁnd assistance when dealing with the problems that can occur in everyday life. To request assistance, just call the St. Bernards Counseling Center at 870.930.9090 or toll-free at 1.800.346.0183.
PTO: PTO is used concurrent while on leave. This means any PTO balance will be used regardless if you have Short Term Disability or not while you are out on leave.
You can get all of the claim forms from your BenefitHUB by choosing the information card for that benefit.

Helpful Tips:

Don’t forget about the employee discounts! You can contact the billing office at 870-207-7222 to have your discount applied to your hospital bills.
Discounts are available on breast pumps at Delta Medical Supplies. The Willow Pump also has a St. Bernards discount code. You will receive a $160.00 reimbursement when you submit a claim form to USAble health insurance.

Willow Breast Pump

Delta Medical Supplies

Medical Reimbursement Form

Spouse Changes

There are a couple of life changing events that qualify as a spouse change. By having a quality support team, it will reduce the stress that couples and families feel during this experience.

Change due to Spouse Benefits

If your spouse has a change in benefits, you may be eligible to update your insurnce plan. You have 31 days from the date of the event to report the change to your employer. Changes can be made to medical, dental, or vision coverage. The following events will allow for a change in benefits.

If the spouse’s employer coverage causing a newly eligible gain or loss of coverage
Spouse changes coverage during Open Enrollment
Divorce
Military Leave
Medicare

Change due to Divorce

When the divorce decree is signed, you may elect any medical coverage you are losing under your spouse’s plan. If you currently cover your spouse, you must drop his or her coverage for medical, dental, vision, and group term life, you are able to continue to cover your children. You will need to complete the appropriate forms and provide a copy of the first and last pages of your certified divorce decree. You should also review your beneficiary designations for life insurance, retirement savings, and pension plans. Prior to the final decree, you may not drop a spouse in anticipation of the final decree.

Remove Spouse from Benefits

If your spouse is no longer eligible for coverage, you should notify HR to remove him or her from the benefit plans. Any stepchildren who are no longer eligible will also need to be removed from the plans. You may also obtain information on Insurance Continuation for your spouse. Conversely, if you and/or your children were covered by your spouse's plan, you will need to enroll yourself or your child/children in the appropriate plan(s).

How To Make Benefit Changes Online

Use the Life Event Instructions link below to create a Life Change Event in the enrollment portal to make changes to benefits. Be sure to upload the required documents to make the change.

Eligible changes include:

Medical
Dental
Vision
Hospital Care
Beneficiaries for Life Insurance

Required Documents:

Provide birth certificate or birthing letter from the hospital
Provide Social Security Number

Review/Change Beneficiaries and Emergency Contact Information:

If you need access to see what benefits you currently have, click on Enrollment Portal link below. Log in the same as you did during open enrollment. If you do not know your password, use the forgot password option. From here, you can change beneficiaries and emergency contact information.

OR Change By Paper Form and send to Human Resources

Retirement Beneficiary Changes

This is also a good time to change your beneficiaries in your retirement. If you are currenly in the TIAA retirement plan, use the link below to log into your account to make the beneficiary changes. If you are in the Pension plan, complete the form below and return to Human Resources.

Life Insurance Claim Form

Social Security Name Change Application

Loss of Loved One

Navigating the grieving process can be challenging, but the other changes associated with the loss of a loved one can also be difficult to comprehend and deal with. Getting your loved one's estate and finances in order, for example, can pose obstacles and certainly many questions. You'll need to review your loved one's papers as well as their benefits package.

Family Medical Leave Act

What is the Family Medical Leave Act (FMLA)? FMLA is a federal law that entitles employees to 12 weeks of unpaid leave for qualifying medical and family reasons. This time can be used over the course of 12 months for qualifying medical and family reasons including loss of a loved one. To start a leave case go to FMLASource or call 877-GO2- FMLA.

FMLA Instructions

FMLASource Website

How To Make Benefit Changes

Use the Life Event Instructions link below to create a Life Change Event in the enrollment portal to make changes to benefits. Be sure to upload the required documents to make the change.

Eligible changes include:

Medical
Dental
Vision
Hospital Care
Beneficiaries for Life Insurance

Required Documents:
Death Certificate; other documents could be required such as accident reports etc. depending on the requirements from the insurance carriers.

Review/Change Beneficiaries and Emergency Contact Information:

If you need access to see what benefits you currently have, click on Enrollment Portal link below. Log in the same as you did during open enrollment. If you do not know your password, use the forgot password option. From here, you can change beneficiaries and emergency contact information.

OR Change By Paper Form and send to Human Resources

Life Insurance Claim Form

Life Insurnace

If you had Life Insurance on your dependent, complete the Life Insurance Claim Form below and submit to USAble Life along with a copy of the death certificate.

Accident, Critical or Hospital

If you have Accident, Critical Care with Cancer or Hospital Care benefits, we have listed the claim forms below for you. If the benefit applies, complete the claim form and send to the "where to submit" at the top of each form.

Accident Claim Form

Critical Claim Form

Hospital Claim Form

Retirement Beneficiary Changes

This is also a good time to change your beneficiaries in your retirement. If you are currenly in the TIAA retirement plan, use the link below to log into your account to make the beneficiary changes. If you are in the Pension plan, complete the form below and return to Human Resources.

TIAA Retirement Online Change

Social Security Name Change Application

Veterans Administration

For assistance in filing claims for veterans and survivor benefits, counseling or emergency financial assistance, contact: Disabled American Veterans P.O. Box 14301 Cincinnati, OH 45250-0301 (606) 441-6300 For information on military funerals, contact: Veterans of Foreign Wars VFW Memorial Building 200 Maryland Avenue, NE Washington, DC 20002 (202) 543-2239.

Status Change

Congratulations on your change of position! It is now time to make benefit changes. Follow the steps below by either going online to make changes or use the paper form.

If you are adding dependents you will need to provide a copy of your certified marriage certificate along with a copy of the spouse driver's license for spouse and for children a birth certificate or court order is required. You should also review your beneficiary designations for life insurance, retirement savings, and pension plans. You must consult the HR Department within 31 days from the date of the event to make changes.

How To Make Benefit Changes Online

Use the Life Event Instruction link below to create a Life Change Event in the enrollment portal to make changes to benefits. Be sure to upload the required documents to make the change.

Eligible changes include:

Medical
Dental
Vision
Hospital Care
Beneficiaries for Life Insurance

Required Documents:

Provide Marriage License
Provide Spouse Driver's License

Review/Change Beneficiaries and Emergency Contact Information:

If you need access to see what benefits you currently have, click on Enrollment Portal link below. Log in the same as you did during open enrollment. If you do not know your password, use the forgot password option. From here, you can change beneficiaries and emergency contact information.

OR Change By Paper Form and send to Human Resources

Retirement Beneficiary Changes

This is also a good time to change your beneficiaries in your retirement. If you are currenly in the TIAA retirement plan, use the link below to log into your account to make the beneficiary changes. If you are in the Pension plan, complete the form below and return to Human Resources.

Tax Forms

To change your tax withholdings, complete the forms below and return to Human Resources. Changes are made on the next payroll.