HealthbyChoice® plan designs

Using our online HealthbyChoice qualification form:

  • Document your patient's status for the health criteria.
  • Indicate whether or not the patient has a health condition that makes meeting the health criteria medically inadvisable, and set an alternate goal if indicated.

Plans effective on or after July 1, 2016:

Qualification period

HbC Motivations: Employers determine the length of the qualification period

HbC Incentives: 90 days from effective date

HbC Progressions: 90 days from effective date

Patient can earn

HbC Motivations: Rewards set by employer

HbC Incentives: Choice level benefits (lower deductible, copays, coinsurance)

HbC Progressions: Choice level benefits (lower deductible, copays, coinsurance)

Health criteria

Tobacco, BMI/waist circumference and BP must be measured within the last 6 months.

Tobacco

HbC Motivations: non-user, including electronic cigarettes1

HbC Incentives: non-user, including electronic cigarettes1

HbC Progressions: non-user, including electronic cigarettes1

BMI

HbC Motivations: < 30 or,

Waist circumference

Male: < 41"

Female: < 35"

HbC Incentives: < 30 or,

Waist circumference

Male: < 41"

Female: < 35"

HbC Progressions: < 30 or,

Waist circumference

Male: < 41"

Female: < 35"

BP

HbC Motivations: < 140/90, or

With diabetes: <140/80

With CVD3: < 140/90

Age 60+: < 150/90

HbC Incentives: < 140/90, or

Age 60+: < 150/90

If any of those are not met, additional requirements are:

Fasting cholesterol test (82465)4

Fasting blood sugar test (82947)4

Provider follow-up plan

HbC Progressions: < 140/90, or

With diabetes: <140/80

With CVD3: < 140/90

Age 60+: < 150/90

LDL cholesterol

HbC Motivations

Healthy: < 190, most recent within the last 5 years, or

With diabetes: < 100

With CVD3: < 100

HbC Progressions: 

Healthy: < 190, most recent within the last 5 years or,

With diabetes: < 100

With CVD3: < 100

Blood sugar

Only required for patients with diabetes or CVD3

HbC Motivations:

With diabetes: < 7% HbA1C5

With CVD3: < 126 FBC6, most recent within the last 3 years

HbC Progressions: 

With diabetes: < 7% HbA1C5

With CVD: < 126 FBC6

1 Any type of tobacco use

2 A member who is pregnant can meet the BMI criteria at the provider's discretion. Write "Pregnant" in the RESULT box and check Yes for CRITERIA MET

3 Cardiovascular disease (CVD) = Heart disease and possible indicators of heart disease, including hyperlipidemia and hypertension

4 Suggested CPT code

5 Suggested CPT code for patients with diabetes: 83036

6 Suggested CPT code for patients with CVD: 82947

Plans effective on or before June 30, 2016:

Qualification period

HbC Motivations: Employers determine the length of the qualification period

HbC Incentives: 90 days from effective date

HbC Progressions: 90 days from effective date

Patient can earn

HbC Motivations: Rewards set by employer

HbC Incentives: Choice level benefits (lower deductible, copays, coinsurance)

HbC Progressions: Choice level benefits (lower deductible, copays, coinsurance)

Health criteria

Tobacco, BMI/waist circumference and BP must be measured within the last 6 months.

Tobacco

HbC Motivations: non-user

HbC Incentives: non-user

HbC Progressions: non-user

Alternate goal: Complete a Priority Health tobacco cessation program.

BMI

HbC Motivations: < 30 unless pregnant

HbC Incentives: < 30 unless pregnant

HbC Progressions: <30 unless pregnant

Alternate goal: Reduce body weight by 5%, or physician-recommended target.

BP

HbC Motivations:

< 140/90, or

< 140/80 for patients with diabetes

HbC Incentives

< 140/90

HbC Progressions

< 30 unless pregnant

Alternate goal: Reduce body weight by 5%, or physician-recommended target.

LDL cholesterol

HbC Progressions:

< 160

< 100 if patient has heart disease or possible indicators of heart disease

Alternate goal: Reduce LDL by 20 mg/dl, or physician-recommended target.

Blood sugar

HbC Progressions (not required for healthy patients):

< 126 fasting for CVD patients

HbA1C < 8% fasting for patients with diabetes

Alternate goal: Reduce HbA1c by 1%, or physician-recommended target.

*National guidelines recommend cholesterol testing for healthy individuals every 5 years and blood glucose testing when indicated.