Deseret Alliance - DMBA
DENHOD1HBA0119DESALL1HBR01212021DESERET ALLIANCEThis summary plan description, or SPD, outlines the major provisions ofDeseret Alliance as of January 1, 2021.DESERET ALLIANCE KEY POINTS Deseret Alliance is a Medicare supplement plan, meaning it providesadditional benefits after Medicare has paid. Medicare is your primary plan provider and Deseret Alliance is yoursecondary plan. You must be properly enrolled in both Medicare Part A and Part B to haveadequate benefits and to be eligible for Deseret Alliance. Also, you mustnot enroll in another Part D Medicare prescription plan. If you do, you’lllose your Deseret Alliance medical and prescription drug benefits andwon’t be able to re-enroll later. Your basic office visit copayments will be no more than 15 and somespecialist office visits copayments will be up to 30. Your annual out-of-pocket maximum is 3,000 per person. You must receive services from providers eligible to bill Medicare and whochoose to accept you as a Medicare patient unless you’re traveling outsidethe United States. The plan partners with Granite Alliance Insurance Company, a subsidiaryof Magellan Rx, to administer your prescription drug benefits. The plan is not designed to pay all amounts not covered by Medicare.1
ENROLLING IN MEDICARE Drugstore purchases of medical supplies andequipmentMedicare is the federal health insurance programthat covers people 65 and older and certain disabledindividuals. It is administered by the Centers forMedicare & Medicaid Services (CMS) of the U.S.Department of Health and Human Services. Flu clinics from a non-Medicare participatingentity (such as the convenient care clinicsfound in retail stores)Key indicators that a provider does not participatewith Medicare include the following:Medicare benefits are divided into three parts: They require full payment up front Part A (hospital insurance) helps pay forinpatient hospital care, inpatient care at askilled nursing facility, some home healthcare,and hospice care. They will not submit the claim to Medicare They ask you to sign a form explaining theyare not participating with MedicareProviders who have completely opted out of theMedicare program, or who have been excluded forcause by Medicare, are not eligible to bill Medicarefor services. Neither Medicare nor DMBA willpay for services performed by an “opted-out” orexcluded provider. (Providers are obligated toinform Medicare patients if they have opted out ofor been excluded from Medicare.) Part B (medical insurance) helps pay fordoctors’ services, outpatient hospital services,durable medical equipment, some homehealthcare, and many other services notcovered by Part A. Part D (prescription drug insurance) helpspay for prescription medications.Generally, you’re automatically enrolled in Part Awhen you turn 65. It’s up to you to enroll in Part Bas soon as you’re eligible. Go to www.medicare.govfor help or call 800-MEDICARE (800-633-4227).If you encounter any of these situations, we stronglyencourage you to find a different provider who isparticipating with Medicare. For help finding aMedicare provider, go to www.medicare.gov.Granite Alliance Insurance Company administersyour Part D prescription drug benefits for you.You should not enroll in another Medicareprescription plan. If you do, you’ll lose yourDeseret Alliance medical and prescription drugbenefits and won’t be able to re-enroll later.IDENTIFICATION CARDSUse your red, white, and blue Medicare card atyour provider’s office.If you misplace or lose your card, call one of thefollowing to get a replacement:MAXIMIZING YOUR BENEFITSMake sure your providers will accept you as aMedicare patient.Medicare800-MEDICARE (800-633-4227)Social Security Administration800-772-1213You can also request a new card atwww.medicare.gov, www.socialsecurity.gov, orwww.ssa.gov.If you use a provider who does not participate inMedicare, you may be “balance billed” 15% morethan Medicare’s allowable amount. Balance-billedamounts are not covered by the plan. You’ll beresponsible for paying any balance-billed amountsto non-participating providers.Use your Deseret Alliance card when you fill yourprescription medications. If you misplace or loseyour Deseret Alliance card, call DMBA MemberServices and we’ll send you a new one.You may not always realize a provider is notMedicare eligible. Here are some examples ofexpenses that aren’t eligible:DMBA Member Services. 801-578-5600 or800-777-3622 Internet purchases of medical supplies andequipment2
When you go to a doctor or hospital, tell themyou’re a participant of Deseret Alliance, aMedicare Supplement plan, and show them bothyour Medicare card and your Deseret AllianceID card. This will let the provider know tosubmit claims directly to Medicare first. AfterMedicare has paid, your claim information willautomatically be forwarded to DMBA.To disenroll or opt out from Deseret Alliance, callDMBA Member Services. If you drop your DeseretAlliance benefits, you cannot re-enroll later.YOUR MEDICAL BENEFITSTo be eligible for payment, services must meetMedicare criteria. To maximize your benefits,confirm with your provider that he or she acceptsMedicare assignment.If your providers have questions about DMBA asyour benefits administrator, ask them to call us at801-578-5600 or 800-777-3622.All benefits are subject to the allowable amountsdetermined by either Medicare or DMBA.Medicare benefit limits also apply. See theMedicare & You handbook for more information.You can access a copy online atwww.medicare.gov/medicare-and-you.If your providers have questions about Medicare’spayment, they should call Medicare directly at800-MEDICARE (800-633-4227).IMPORTANT RULES ANDGUIDELINESSERVICES NOT COVERED BYMEDICAREIf Medicare doesn’t cover a specific service,neither will Deseret Alliance—except for a fewsupplemental services, such as annual physicalexams, routine eye exams, and hearing aids.ANNUAL ROUTINE EYE EXAMExcept for a few medications, preauthorizationis not required. See Preauthorization for SpecificMedications.Deseret Alliance pays 100% of DMBA’s allowableamount after your 15 copayment.Deseret Alliance will only coordinate withMedicare Parts A, B, and C (Medicare Advantageplan without prescription drug benefits). If you’reconsidering other Medicare supplement benefits,keep in mind that Deseret Alliance will notcoordinate with them.One exam per calendar year is eligible.You pay up to a 15 copayment.ANNUAL ROUTINE PHYSICAL EXAMDeseret Alliance pays 100% of DMBA’s allowableamount.You pay 0.You cannot be enrolled in Deseret Alliance andanother Medicare Part D Prescription Drug Plan(other than the Granite Alliance PDP) at the sametime. It’s your responsibility to inform DMBA ofany other medical or prescription drug benefitsyou have now or in the future.One exam per calendar year is eligible.Some services may not be eligible as part of aphysical exam.Labs and routine procedures associated with anineligible physical exam are not covered.As a Deseret Alliance participant, you have theright to appeal plan decisions about payments orservices. If your appeal is related to Medicare’spayment, you must appeal directly to Medicare.For information about appealing Deseret Alliancepayment decisions, see Claims Review and AppealProcedures.BENEFITS FOR FOREIGN MISSIONARIESDeseret Alliance pays 100% of DMBA’s allowableamount after any applicable copayments andcoinsurance.You pay applicable copayments and coinsurance.All benefits are subject to DMBA’s allowable amounts.3
SERVICES COVERED BYMEDICARE PART AThis benefit applies if you receive Medicare PartB services in the United States only while you’redisenrolled from Part B because of voluntaryforeign missionary service.HOME HEALTH SERVICESBENEFITS DURING FOREIGN TRAVEL (WHENYOU’RE OUTSIDE THE U.S.)Medicare pays 100% of Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount in limited circumstances only.Deseret Alliance pays 0.You pay 0.Deseret Alliance pays 20% of the Medicareapproved amount minus any copayments andcoinsurance if covered by Medicare; or 100% of allcovered services up to the billed amount, minus anycopayments and coinsurance (based on the type ofservice received) if not covered by Medicare.HOSPICE CAREMedicare pays 100% of Medicare-approvedamount.Deseret Alliance pays 0.You pay applicable copayments and coinsurance.You pay 0.EYE REFRACTION EXAMSHOSPITAL CARE—INPATIENT (INCLUDINGMENTAL HEALTH INPATIENT CARE)Deseret Alliance pays 100% of DMBA’s allowableamount.Days 1 to 60You pay 0.Medicare pays 100% after your Medicare Part Adeductible ( 1,484 in 2021).HEARING AIDSDeseret Alliance pays 100% of the Medicare PartA deductible minus 750.Deseret Alliance pays 100% of DMBA’s allowableamount after applicable copayments.You pay up to 750 copayment.You pay applicable copayments:Days 61 to 90 399 copayment per aid for Advanced modelMedicare pays 100% after your Medicare Part Adaily coinsurance amount ( 371 per day in 2021). 699 copayment per aid for Premium model 50 per aid to change from battery-powered torechargeableDeseret Alliance pays 100% of the Medicare PartA daily coinsurance amount.One hearing aid per ear from TruHearing iseligible annually.You pay 0.Services from all other providers are not eligible.After day 90 (per benefit period)To learn more or to schedule an appointment witha TruHearing-contracted provider in your area,call 866-929-5584.Medicare pays 0, unless Medicare’s lifetimereserve days are used.After day 90 (per benefit period when lifetime reservedays are exhausted)IMMUNIZATIONS NOT COVERED BY MEDICAREDeseret Alliance pays 0.Deseret Alliance pays 100% of DMBA’s allowableamount for approved immunizations.You pay 100% for inpatient days that exceedMedicare’s day limit.You pay 0.All benefits are subject to DMBA’s allowable amounts.4
AMBULANCE SERVICESLifetime reserve daysMedicare pays 100% after your Medicare Part Adaily coinsurance amount ( 742 per day in 2021)for days 91 to 150.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 20% of the Medicareapproved amount minus a 75 copayment.Deseret Alliance pays 100% of the Medicare PartA daily coinsurance amount.You pay up to a 75 copayment per day.You pay 0.AMBULATORY SURGICAL CENTERSKILLED NURSING FACILITY CAREMedicare pays 80% of the Medicare-approvedamount.Days 1 to 20Medicare pays 100%.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 275 copayment.Deseret Alliance pays 0.You pay 0.You pay up to a 275 copayment.Days 21 to 100CARDIAC REHABILITATION (OUTPATIENT)Medicare pays 100% after your Medicare Part Adaily coinsurance amount ( 185.50 per day in2021).Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.Deseret Alliance pays 100% of the remainingMedicare-approved amount minus a 100copayment per day.You pay up to a 15 copayment per visit.You pay up to a 100 copayment per day.After day 100 (per benefit period)CHEMOTHERAPYMedicare pays 0.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 0.Deseret Alliance pays 10% of the Medicareapproved amount.You pay 100%.SERVICES COVERED BYMEDICARE PART BYou pay 10% coinsurance.CHIROPRACTIC SERVICES (LIMITED)Medicare applies an annual Medicare Part Bdeductible ( 203 in 2021). No payment for chargesis made until the deductible has been met.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance covers the Medicare Part Bdeductible minus applicable copayments andcoinsurance.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay the applicable copayment andcoinsurance for the service provided.Up to 25 visits per calendar year are eligible.You pay up to a 15 copayment per visit.All benefits are subject to DMBA’s allowable amounts.5
DIABETES SELF-MANAGEMENT TRAININGDOCTOR AND OTHER HEALTHCARE PROVIDERSERVICES—OUTPATIENTMedicare pays 80% of the Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 20% of the Medicareapproved amount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 30 copaymentper day.You pay 0.DIABETIC SUPPLIESYou pay up to a 30 copayment per day.Medicare pays 80% of the Medicare-approvedamount.DURABLE MEDICAL EQUIPMENTMedicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.Deseret Alliance pays 10% of the Medicareapproved amount.You pay 10% coinsurance.Eligible supplies:You pay 10% coinsurance. Blood sugar testing monitorsEMERGENCY DEPARTMENT SERVICES Blood sugar test strips Lancet devices and lancetsMedicare pays 80% of the Medicare-approvedamount. Therapeutic shoes (in some cases)Some supplies are covered by the prescriptiondrug benefit.Deseret Alliance pays 20% of the Medicareapproved amount minus a 65 copayment per day.You pay up to a 65 copayment per day.DIALYSISThe copayment is waived if the patient is admittedto the hospital from the emergency room.Medicare pays 80% of the Medicare-approvedamount.EYEWEAR—GLASSESDeseret Alliance pays 10% of the Medicareapproved amount.Medicare pays 80% of the Medicare-approvedamount.You pay 10% coinsurance.Deseret Alliance pays 10% of the Medicareapproved amount.DOCTOR AND OTHER HEALTHCARE PROVIDERSERVICES—INPATIENTYou pay 10% coinsurance.Medicare pays 80% of the Medicare-approvedamount.Glasses are covered only after cataract surgery.HEARING EXAMSDeseret Alliance pays 20% of the Medicareapproved amount.Medicare pays 80% of the Medicare-approvedamount.You pay 0.Some physician services you receive whileadmitted to the hospital are eligible.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.All benefits are subject to DMBA’s allowable amounts.6
You pay up to a 15 copayment per visit.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 30 copaymentper day.Routine hearing exams are not covered.INJECTIONS AND IV THERAPYYou pay up to a 30 copayment per day.Medicare pays 80% of the Medicare-approvedamount.Outpatient surgeryMedicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 275 facilitycopayment per surgery.You pay 10% coinsurance.MENTAL HEALTHCARE—OUTPATIENTEVALUATION, THERAPY, AND MEDICATIONMANAGEMENTYou pay up to a 275 facility copayment.PARENTERAL NUTRITION SERVICESOffice visit to diagnoseMedicare pays 80% of the Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay 10% coinsurance.You pay up to a 15 copayment per visit.PHYSICAL THERAPYCounseling for outpatient treatmentMedicare pays 80% of the Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay up to 15 copayment per visit.You pay up to a 15 copayment per visit.PRESCRIPTION DRUGS COVERED BY MEDICAREPART BOCCUPATIONAL THERAPYMedicare pays 80% of the Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay 10% coinsurance.You pay up to a 15 copayment per visit.PREVENTIVE SERVICES (SCREENING EXAMS)OUTPATIENT HOSPITAL SERVICESMedicare pays 100% of the Medicare-approvedamount.Clinic visitsDeseret Alliance pays 0.Medicare pays 80% of the Medicare-approvedamount.You pay 0.All benefits are subject to DMBA’s allowable amounts.7
PROSTHETIC/ORTHOTIC ITEMSURGENT CAREMedicare pays 80% of the Medicare-approvedamount.Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay 10% coinsurance.You pay up to 15 copayment per visit.RADIOLOGY (IMAGING)MEDICARE PART DPRESCRIPTION DRUG BENEFITS(FROM YOUR GRANITE ALLIANCEPDP)Medicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 10% of the Medicareapproved amount.You pay 10% coinsurance.Because Granite Alliance Insurance Companyadministers your prescription benefits, pleasedirect medication and prescription questions tothem, toll free, at 855-586-2573 (TTY 711).X-rays, MRIs, MRAs, CT scans, PETs, SPECTs,etc. are eligible.SPEECH LANGUAGE PATHOLOGY SERVICESUse Magellan Rx Pharmacy for your mail-orderprescriptions.Medicare pays 80% of the Medicare-approvedamount.Here’s a summary of your prescription benefitsfrom Granite Alliance Insurance Company.Limitations, copayments, and restrictions mayapply.Deseret Alliance pays 20% of the Medicareapproved amount minus up to a 15 copaymentper visit.You pay up to 15 copayment per visit.SUPPLIESMedicare pays 80% of the Medicare-approvedamount.Deseret Alliance pays 20% of the Medicareapproved amount.You pay 0.TESTS (LAB TESTS)Medicare pays 100% of the Medicare-approvedamount.Deseret Alliance pays 0.You pay 0.A1C, urinalysis, blood chemistry, glucose, lipidprofile, etc. are eligible.All benefits are subject to DMBA’s allowable amounts.8
Prescription categoryFor a 30-day supply from a retailpharmacy you’ll pay . . .For a 90-day supply from a mail-orderor retail pharmacy you’ll pay . . .Tier 1:Preferred generic medications25%, or at least 525%, or at least 10,but no more than 225Tier 2:Preferred brand-name medications25%, or at least 525%, or at least 10,but no more than 225Tier 3:Non-preferred medications (generic and brand-name)50%, or at least 5*50%, or at least 10*Tier 4:Specialty medications25%, or at least 150, but no more than 225100% (not covered)Catastrophic coverage: Brand-name medications5%, or at least 8.505%, or at least 8.50Catastrophic coverage: Generic medications5%, or at least 3.405%, or at least 3.40Excluded medications100% (not covered)100% (not covered)* Reduced to 25% coinsurance after your total payments for prescriptions reach 4,130 in 2021.Prescription drug expenses don’t count towardyour out-of-pocket maximum.If you don’t preauthorize when necessary, yourbenefits may be reduced or denied.Some injections, oral cancer drugs, drugs usedwith durable medical equipment, and drugs givenin a hospital setting are not covered.MEDICAL EMERGENCIESA medical emergency is when you reasonablybelieve your health is in serious danger and everysecond counts. This includes severe pain, a badinjury, a serious illness, or a medical conditionthat is quickly getting much worse.SUPPLIES USED TO ADMINISTER DIABETESMEDICATIONSDeseret Alliance pays 90% of the allowableamount.If you have an emergency, go to the nearestemergency room or call 911 for help.You pay 10%.Syringes, needles, alcohol swabs, gauze, andinhaled insulin devices are eligible.OUT-OF-POCKET MAXIMUMIf your share of eligible medical expenses reaches 3,000 per calendar year (your annual out-ofpocket maximum), your medical benefits for theremainder of the calendar year are paid at 100%for eligible charges, based on the out-of-pocketmaximum of the plan.PREAUTHORIZATION FORSPECIFIC MEDICATIONSPreauthorization means Granite Alliance isnotified in advance about specific medicationsyour doctor has prescribed. Then Granite Alliancecan tell you what will be covered before you’refaced with your share of the costs.Some benefits do not apply to your out-ofpocket limit, so they’re not covered by the outof-pocket maximum. These include prescriptionmedications, except for drugs that are traditionallycovered by Medicare Part B. See Medicare Part Dprescription drug benefits.Preauthorization is only required for certainmedications. The Granite Alliance formulary druglist includes information about which medicationsrequire preauthorization. If you have questionsabout your personal situation, please call GraniteAlliance Customer Service.For information about the out-of-pocket limit foryour prescription benefits from Granite Alliance,All benefits are subject to DMBA’s allowable amounts.9
4. Fill out a Medical & Dental Claim Form,which you can find in the Forms Library atwww.dmba.com.refer to your Granite Alliance PDP Evidence ofCoverage.ERRORS ON BILLS OR EOBSTATEMENTS5. Mail the claim to DMBA:DMBAP.O. Box 45530Salt Lake City, UT 84145If you see services listed on an Explanation ofBenefits (EOB) statement that were not performedor could be considered fraudulent, please callDMBA at 801-578-5600 or 800-777-3622.You must submit pharmacy claims to GraniteAlliance, not DMBA. For more information, referto your Granite Alliance PDP Evidence of Coverage.If you find an error on any of your bills after yourclaims have been processed and paid, please verifythe charges with your provider. Then submit awritten description of the error to DMBA:To be eligible for benefits, medical claims mustbe submitted by you or your provider within12 months from the date of service. It is yourresponsibility to ensure this happens. DMBA sendsyou an EOB when your claims have been processed.Please review all your EOBs for accuracy.DMBAP.O. Box 45530Salt Lake City, UT 84145COORDINATION OF BENEFITSIf you find an error on any claims related toMedicare’s payment, please contact Medicare aswell.When you or your dependents have medical ordental benefits from more than one health plan,benefits are coordinated between the plans toavoid duplication of payments. Coordinationof benefits involves determining which insureris required to pay benefits as the primary payer,which insurer must pay as the secondary payerand so on.SUBMITTING CLAIMSFor services from Medicare-eligible providers, youshould not need to submit claims. These providerssend bills directly to Medicare for processing. Butyou could receive a bill for services you receivewhen you’re traveling outside the United States.You or your dependents must inform DMBA ofother medical or dental benefits in force when youenroll or when other benefits become effective. Ifapplicable, you may be required to submit courtorders or decrees. You must also keep us informedof any changes in the status of the other benefits.If you receive a bill for medical services, followthese steps to submit a claim:1. Get an itemized bill from the provider orfacility that includes the following: Patient’s nameMultiple health plans Provider’s name, address, phone number,and tax identification numberAs a participant in Deseret Alliance, you mustimmediately notify DMBA if you’re enrolled inany other plan while you’re concurrently enrolledin Deseret Alliance. Diagnosis and diagnosis code(s) Procedure and procedure code(s) Place and date of service(s)You’re also prohibited from enrolling in certaintypes of plans while you’re enrolled in thisplan, as described below. If you’re concurrentlyenrolled in any of the following plans, you will beinvoluntarily disenrolled from Deseret Allianceand be unable to reenroll in the future: Amount charged for service(s)2. Write your name and DMBA ID number onthe bill.3. Have the provider indicate the amount ofpayment already collected, if applicable.10
» Workers’ compensation A Medicare Advantage Plan that includes drugbenefits (Part D)» An active group health plan after thethirtieth month of end-stage renal diseasebased eligibility Another Medicare Part D plan (other than yourGranite Alliance PDP) An employer-based Medicare supplement planthat includes drug benefitsSUBROGATIONOrder of paymentIf you have an injury or illness that is the liabilityof another party and you have the right to recoverdamages, DMBA requires reimbursement for theamount it has paid when damages are recoveredfrom the third party.The primary payer pays up to the limits of itsbenefits. The secondary payer only pays if thereare expenses the primary payer did not cover. Thesecondary payer may not pay all of the uncoveredcosts.If you do not attempt to recover damages fromthe third party as described above, DMBA hasthe right to act in your place and initiate legalaction against the liable third party to recover theamount it has paid for your injuries.Coordination with other plansDeseret Alliance will only coordinate with otherplans as outlined here:For more information about subrogation, pleasesee your General Information SPD. Deseret Alliance and Medicare Parts A andB: Medicare pays first and Deseret Alliancepays second.ELIGIBLE DEPENDENTS Deseret Alliance and a Medicare AdvantagePlan without prescription drug benefits(known as Part C only): Medicare AdvantagePlan pays first and Deseret Alliance payssecond.Your eligible dependents include your spouse anddependent children. Your spouse is the person towhom you are legally married.EXCLUSIONS Deseret Alliance, Medicare Parts A and B,and a non-DMBA group health plan: Thegroup health plan pays first, Medicare payssecond, and Deseret Alliance pays third.Services that do not meet the definition of eligible,as previously defined, are not eligible for benefits.All procedures or treatments are excluded untilspecifically included in the plan. To be eligible forpayment, services must meet Medicare’s criteria.In addition, the following services and theirassociated costs are excluded from benefits: Deseret Alliance, Medicare Parts A andB, and TRICARE or Medicaid: Medicarepays first, Deseret Alliance pays second, andTRICARE or Medicaid pays third. Deseret Alliance, Medicare Parts A and B,and another third-party insurance (notedbelow): The third-party insurer pays first,Medicare pays second, and Deseret Alliancepays third.1. Custodial care1.1» No-fault insurance (including automobileinsurance)» Liability insurance (including automobileinsurance)» Black lung benefits11Custodial or long-term care, education,training, or rest cures, which is defined asmaintaining an individual beyond the acutephase of injury or sickness and includesroom, meals, bed, or skilled or unskilledmedical care at any hospital, care facility, orhome to assist the individual with activitiesof daily living including, but not limited to,feeding, bowel and bladder care, respiratory
support, physical therapy, administration ofmedications, bathing, dressing, or ambulation;and where the individual’s impairment,regardless of the severity, requires suchsupport to continue for more than two weeksafter establishing a pattern of this type of care,except as provided for by the terms of the plan1.2 The technology has final approvalfrom all appropriate governmentalregulatory bodies, if applicable. (FederalDrug Administration approval doesnot necessarily mean a service is notinvestigational/experimental.) The technology is available in significantnumbers outside the clinical trial orresearch setting.Inpatient hospitalization or residentialtreatment for the primary purpose ofproviding shelter or safe residence The available research about the technologyis substantial.2. Dental care2.1For plan purposes, substantial meanssufficient to allow DMBA to conclude that thetechnology isDental services, including care andtreatment of the teeth, gums, or alveolarprocess; dentures, crowns, caps, permanentbridgework, and appliances; and suppliesused in such care and treatment, except asprovided for by the terms of the plan both medically necessary and appropriatefor the covered person’s treatment, safe and efficacious,3. Diagnostic and experimental services more likely than not beneficial to thecovered person’s health, and3.1 generally recognized as appropriate by theregional medical community as a whole.3.2Care, service, diagnostic procedures, oroperations for diagnostic purposes not relatedto an injury or sickness, except as providedfor by the terms of the planA service, care, treatment, or operation fallingin these categories will continue to be excludeduntil the plan administrator determines that itmeets all such criteria and specifically includesit as a covered service in the plan.Care, treatment, diagnostic procedures, oroperations that are considered medical research; investigative/experimental technology(unproven care, treatment, procedures, oroperations);4. Fertility, infertility, family planning,home delivery, surrogate pregnancy,and adoption not recognized by the U.S. medicalprofession as usual and/or common;4.1Family planning, including contraception,birth control devices, and/or sterilizationprocedures, unless the covered individualmeets DMBA’s current medical criteria4.2Abortion and medications to induce abortion,except in cases of rape, incest, or when the lifeof the mother and/or fetus would be seriouslyendangered if the fetus were carried to term4.3Services related to in vitro fertilization that donot meet plan guidelines4.4Reversal of sterilization procedures4.5Planned home delivery for childbirth and allassociated costs determined by DMBA not to be usual and/or common medical practice; or illegalThat a physician might prescribe, order,recommend, or approve services or medicalequipment does not, of itself, make it anallowable expense, even though it is notspecifically listed as an exclusion.Investigative/experimental technology means aservice, procedure, facility, equipment, drug,device, or supply that does not, as determinedby DMBA, meet all of the following criteria:12
4.6All pregnancy- and birth-related expenses(prenatal and postnatal) of an individual(including a covered individual) acting as asurrogate or gestational carrier*4.7Services, drugs, or supplies to treat sexualdysfunction, erectile dysfunction, enhancesexual performance, or increase sexual desire,except the external erectile vacuum erectiondevice under the durable medical equipmentbenefitnot criminal charges are filed or a conv
your Medicare card and your Deseret Alliance ID card. This will let the provider know to submit claims directly to Medicare first. After Medicare has paid, your claim information will automatically be forwarded to DMBA. If your providers have questions about DMBA as your benefits administra
F Obtain your retirement estimates at www.dmba.com using DMBA’s pension calculator. F Review and choose a retirement benefit payment option. (See page 10.) F Three months before retirement, complete the online Retirement Benefits Application at www.dmba.com. 4. DESERET 401(K) PLAN F Verify you’re saving enough to be ready for retirement.
DESERET PROTECT This summary plan description, or SPD, outlines the major provisions of Deseret Protect as of January 1, 2022. . Your annual out-of-pocket maximum is 5,600 per person or 8,400 per family. Due to Deseret Protect's low premiums, some services are not covered, including acupuncture, allergy testing, injections .
Deseret Value has an annual deductible of 400 per person or 800 per family for services from non-contracted providers. Your annual out-of-pocket maximum is 5,600 per person or 8,400 per family. You or your physician must preauthorize some services with DMBA, such as some surgeries and home healthcare. Maximizing Your Benefits
Deseret Premier has an annual deductible of 400 per person or 800 per family for services from non-contracted providers. Your annual out-of-pocket maximum is 2,800 per person or 5,600 per family. You or your physician must preauthorize some services with DMBA, such as some surgeries and home healthcare. Maximizing Your Benefits
DESERET SELECT This summary plan description, or SPD, outlines the major provisions of Deseret Select as of January 1, 2022. . Your annual out-of-pocket maximum is 2,800 per person or 5,600 per family for services from contracted providers and 5,600 per person or 11,200 per family for
Key Points of the Plan The Deseret 401(k) Plan is a traditional safe harbor defined contribution plan to which you contribute a percentage of your eligible salary and your employer matches a percentage of your contributions. You control how your contributions and your employer's contributions are invested.
The implementation guide specifies in detail the required formats for transactions exchanged electronically with an insurance company or healthcare payer. The implementation guide contains requirements for the use of specific segments and specific data elements within those segments and applies to all healthcare providers and their trading .
Agile Software Development with Scrum Jeff Sutherland Gabrielle Benefield. Agenda Introduction Overview of Methodologies Exercise; empirical learning Agile Manifesto Agile Values History of Scrum Exercise: The offsite customer Scrum 101 Scrum Overview Roles and responsibilities Scrum team Product Owner ScrumMaster. Agenda Scrum In-depth The Sprint Sprint Planning Exercise: Sprint Planning .
