HealthbyChoice Achievements explained
Learn about how HealthbyChoice Achievements® works:
Standard vs. Choice benefits
HealthbyChoice Achievements features two levels of benefits:
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Standard: The same great benefits, but members must pay more for copays, deductibles/out-of-pocket costs and coinsurance.
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Choice: Outstanding benefits that let members save on copays, deductibles/out-of-pocket costs and coinsurance.
All members start out in the Standard benefit level.
Achieving Choice benefits
An employee and their spouse can choose to earn the Choice level of benefits by meeting these requirements:
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Online health risk appraisal: Complete the online health risk appraisal, which is available through their Member Center here on priorityhealth.com.
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Meet 5 wellness criteria: Visit their doctor and have them document the employee meets these criteria:
| Five key wellness criteria |
|---|
| Wellness criteria* |
Qualification requirements |
| Tobacco use |
Non-tobacco user |
| Body mass index (BMI) |
Below 30 |
| Blood pressure |
Below 140/90 |
| Cholesterol |
LDL below 160 |
| Blood sugar |
Without diabetes: Normal
With diabetes: HbA1c <8% |
Once we know the member and spouse have completed the online health risk appraisal and achieved the 5 criteria, then we'll move the member(s) to the Choice benefit level. The date of the move is known as their "achievement date." Jump down to learn more about achievement dates.
If your employees recently had a physical
Employees who had a physical in the last 6 months and whose doctors have information supporting the 5 health criteria can have their doctor fill out a qualification form. Employees may need to see their doctor again about any criteria they didn't meet. Remember, if an employee sees their PCP before your plan effective date, expenses for that visit are covered by your previous plan, not the new plan.
Achievement date: what is it and why is it important?
The achievement date is the date the employee qualifies for Choice benefits and starts paying lower copays and deductibles. It's either the date the employee took the online health risk appraisal or the date the employer visited their doctor and passed all criteria, whichever happened last. Remember, the employee and the spouse must complete both qualification requirements in order to receive Choice benefits.
Example: If the member completes their requirements on February 10, but the spouse doesn't complete their requirements until June 2, then this couple's/family's achievement date is June 2.
There is no deadline for members to complete their requirements and achieve the Choice benefit level. They can do it any time during the plan year.
The achievement date is almost always different from the plan renewal date (or effective date). If a member would like to qualify for Choice benefits on the renewal date, they need to:
- Have visited their PCP within the last 6 months, and their doctor can report passing values for all health criteria. They can submit a completed qualification form on or after the plan's effective date.
- Have taken the online health risk appraisal within the last 6 months.
If a member recently had a physical
Members who had a physical in the last 6 months and whose doctors have information supporting the 5 health criteria can have their doctor fill out a qualification form. Members may need to see their doctor again about any criteria they didn't meet. Remember, if a doctor visit takes place before the member's plan effective date, expenses for that visit are covered by the previous plan, not the new plan.
Move to Choice anytime
- There is no deadline for members to complete their requirements and achieve the Choice benefit level. They can do it any time during the plan year.
- Choice level benefits start on the member's achievement day - the date they complete the online health risk appraisal and meet the 5 criteria on the qualification form (whichever is later).
Spouses & dependents
- Both the member and spouse (if covered) must qualify to achieve the Choice benefit level. If one does and the other doesn't, then they'll both remain at the Standard benefit level until the other achieves their goals.
- Children and adult dependents do not need to qualify.
Not achieving Choice benefits
Members who don't meet the requirements remain at the Standard benefit level. But they can try again to achieve the Choice benefit level by meeting the criteria they failed. We have different ways to help depending on why they didn't meet requirements.
Health condition
If a member has a medical condition that would prevent them from meeting the requirements, they can still qualify for the Choice benefit level by:
- Working with their PCP to create new goals based on the doctor's recommendations
- Participating in our case management program. In this program, the member works with a case manager (nurse or fully-credentialed clinician) to manage their health condition and achieve the goals set by their doctor.
- Meeting the new goals and having their doctor resubmit the qualification form
No health condition
If a member does not have a medical condition that would prevent them from meeting the requirements, we're here to help them with free, one-on-one health coaching services. Members can get confidential support and resources to help them improve their health.
Plan renewal and requalifying for Choice benefits
- On the plan renewal date, the member stays at their same benefits level (Standard or Choice), even if the group changes HealthbyChoice Achievements plan designs (for instance if they go from HMO option 1 to HMO option 3).
- To keep Choice benefits, a member must requalify (retake the online health risk appraisal and have their PCP submit a new qualification form) before their next achievement date.
- If the member doesn't requalify, they'll be moved to the Standard level of benefits on their achievement date.
- If a member qualifies one year, then fails to meet one of the health criteria the next year, they'll move to the Standard level of benefits on their achievement date. They'll stay at Standard until they requalify. At that time, they'll get a new achievement date.
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Remember: Members can move to Choice on the day they meet their qualifications, but they can only move to Standard benefits on their achievement date anniversary.
