HealthbyChoice Progressions explained
Information to guide you through your HealthbyChoice ProgressionsSM plan.
Learn about:
Standard vs. Choice benefits
Achieving the Choice benefit level
Online health risk appraisal
Not achieving Choice benefits
Standard vs. Choice benefits
All employees start at the Standard level of benefits. They can choose to meet 2 requirements and achieve the Choice benefit level, where they'll get lower:
- Copays
- Deductibles/out-of-pocket costs
- Coinsurance
Spouse benefits
- Both the employee 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 meet the requirements.
Premium rates
Your premium rates are based on a combined rate, not on how many employees are at each benefit level. Your rates will remain the same, regardless of who achieves Choice benefits and who stays at Standard benefits.
Achieving the Choice benefit level
An employee and their spouse can choose to earn the Choice level of benefits by meeting these requirements:
-
Online health risk appraisal: Complete the online health risk appraisal, which is available through their Member Center here on priorityhealth.com. Learn more about the appraisal below.
-
Meet 5 wellness criteria: Visit their doctor and have them document the employee meets these criteria:
| Five key wellness criteria |
|---|
| Wellness criteria* |
Automatic qualification |
Progression qualification |
| Tobacco use |
Non-tobacco user |
Non-tobacco user |
| Body mass index (BMI) |
Below 30 |
5% reduction in body weight |
| Blood pressure |
Below 140/90 |
Reduce systolic by 10mm, reduce diastolic by 5mm |
| Cholesterol |
LDL below 160 |
Reduce LDL by 20 mg/dl |
| Blood sugar |
Without diabetes: Normal
With diabetes: HbA1c <8% |
Without diabetes: Normal
With diabetes: reduce HbA1c by 1% |
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 employee 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.
Online health risk appraisal
- A fast and easy way for your employees to gauge their health.
- Employees can easily identify health issues they need to work on and receive recommendations for improving their health.
- Employees can update their appraisal any time to track their progress toward health goals.
- You will never see an individual employee's health risk appraisal results or know which employees are on either benefit level.
Watch a short video about the online health risk appraisal - 3 min.
All employees must create an online account to get to the online health risk appraisal.
See how to create an online account and how to log in.
Not achieving Choice benefits
Members who don't meet the requirements remain at the Standard benefit level. But they can try again to progress to 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 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, they can still qualify for the Choice benefit level by meeting alternative requirements for the criteria they failed.
We can help these members with free, personalized health coaching. Here's how they can participate:
- The member must contact Customer Service to request free health coaching.
- A health coach will contact the member confidentially via email or phone for one-on-one help. The health coach will provide support and resources to help the member improve their health.
Their doctor must resubmit the qualification form. The member's achievement date will be the day their doctor says they met their goals.
