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Deltas HealthyRewards Program
The crisis is real. Chronic diseases, such as diabetes and heart disease, are steering healthcare costs over the cliff. It is estimated that healthcare costs for chronic disease treatment account for over 75% of health expenditures; an expense shared by employers and employees. These common and extremely costly diseases are often treatable, or completely preventable, when people pursue a healthy lifestyle.
Helping You Navigate the Winding Road of Healthcare Reform
Cost ControlDelta manages
plan cost by encouraging
health awareness and
I N T R O D U C I N G H E A LT H Y R E W A R D SDelta Health Systems has designed a new benefi t plan that combines health-conscious programs with the administration needed to produce results. Healthy Rewards emphasizes and rewards impactful consumerism, raises health awareness, and meets the demands of the Patient Protection and Affordable Care Act.Key components of the plan are:
Programs that provide a clinical benchmark and annual results for each member
Care management tools to assist with positive behavior change
The fi rst step is an annual health evaluation for plan members. These can be conducted at employer sites or contracted lab facilities. The comprehensive evaluation includes the following:
34-36 blood panel
Blood pressure test
Abbreviated health risk assessment
Participants receive a concise, easy-to-understand health report that outlines evaluation results, reviews potential health problems, and lists personalized strategies that promote better long-term health.
Delta handles the administration of Healthy Rewards in conjunction with the client and broker.
Delta will: Schedule, promote, and market the evaluations
to plan members.
Provide a participant report to the client within two weeks of the evaluation periods closure during year one.
Provide a participant report within four weeks in year two and beyond.
C U S TO M I Z A B L E P R O G R A M SClients have the option to customize their own program with additional compliance levels, including:
Mandatory care management engagement programs for at-risk members
Preventive care compliance for all plan members over 18 years of age, including annualscreenings and other clinical tests
Customization also includes compliance for specifi c conditions that utilize evidence-based guidelines. For example, specifi c guidelines for diabetics include:
Eye exam in last 12 months
HbA1c test in last 12 months
Infl uenza immunization
P E R S O N A L H E A LT H S C O R EParticipants receive a Personal Health Score that is calculated based on:
Blood Pressure LDL Cholesterol
H I PA A- C O M P L I A N T G O A L SThe members Personal Health Score is used to produce a 12-month, HIPAA-compliant personal health goal. The goal can be achieved through a combination of direct physician supervision and lifestyle changes. By meeting or exceeding goals, participants can reduce the risk of heart disease, diabetes, stroke and other conditions.
LDL test in last 12 months (1875 yrs. old) (HEDIS)
Lipid profi le in last 12 months
Important Elements of Healthy Rewards
Healthy Rewards incents members to participate by
reducing their contribution levelsup to 30% of the
benefi t value.
Healthy Rewards includes components of TeamCare, Deltas comprehensive wellness and care management solution. TeamCare empowers individuals to improve their health, while helping to reduce utilization and lower healthcare spending. An employer can design its benefi t plan to take advantage of any or all of the programs available from TeamCare. While these programs are not required, they are highly recommended to achieve the best results.
Choose the TeamCare programs that are right for your organization. They include:
Utilization Review/Case ManagementURAC-accredited programs that involve our specialized team of doctors and nurses who produce favorable patient outcomes at the lowest possible costs. And, our masters degree-level educators develop lifestyle management programs that help members make healthier choices, thus reducing the incidence of complications and future medical costs.
Wellness ProgramsSupport participants in maintaining healthy habits and help those at risk to set goals that reduce the chances of a future disease. Wellness coaches are available for one-on-one counseling in areas of weight management, stress, nutrition, exercise, and tobacco cessation. Various online services are available through our web portal.
Disease ManagementTargets chronic conditions, such as diabetes and asthma; evidence-based guidelines are used to impact health and measure improvements.
Maternity ManagementProvide education and support to expectant mothers in order to reduce instances of complications and subsequent high claims costs.
Requires use of PPO Network Facilities100% Benefi t at PPO Facilities (no Deductible) No Benefi t at Non-PPO Facilities (except as noted below*)
$100 ER Co-Pay (Waived if admitted)
100% Benefi t at PPO Facilities (no Deductible) No Benefi t at Non-PPO Facilities (except as noted below*)
100% to a maximum of 120 days per stay
100% at PPO FacilitiesNo Benefi t at Non-PPO Facilities (except as noted below*)
Benefi tsDoctor VisitsX-rays and LabAmbulance Surgeon and Related Services
Chiropractic Physical TherapySpeech TherapyOccupational Therapy
Hearing Aid and Testing
Preventive Care, RoutinePhysicals and Immunizations
This is the maximum you will pay in out-of-pocket expenses; once you have reached this amount, the plan will cover 100% per person per calendar year
*In the case of an emergency admission to a Non-PPO Hospital, the PPO Percentage rate will continue only until the doctor verifi es that you or your dependents condition is stable, recovering and is no longer life threatening. If there are no PPO Providers within a thirty mile radius of your residence, or if you or your dependent requires services only available at a Non-PPO Provider, the PPO Percentage rate will apply.
Requires use of PPO Network Providers
No Deductible70% Coinsurance for PPO ProvidersNo Benefi t for Non-PPO Providers (except as noted below*)
$1,500 calendar year maximum24 visit maximum24 visit maximum24 visit maximum
$800 maximum benefi t
100% Benefi t for PPO Providers OnlyNo Benefi t for Non-PPO Providers
$5,000 Per Year Maximum Out of Pocket for Individuals$10,000 Per Year Maximum Out of Pocket for Families
Inpatient and Outpatient Admissions
Skilled Nursing Facility
Mandatory Centers of Excellence
M E D I CA L B E N E F I T S
Healthy Rewards Plan Example
M E N TA L H E A LT H
P R E S C R I P T I O N D R U G S
InpatientInpatient / Residential
Alcohol & Substance Abuse
OutpatientDay Care ProgramOffi ce Visit
Through designated PBMGeneric Drugs mandatory when available.
DAW (Dispensed as Written if preauthorized)
Single ContributionSingle Incentive Contribution**
Family ContributionFamily Incentive Contribution** January 2013 to December 2013
30 day maximum per lifetime100% PPO Facility
90% at TARP Contracted Facility
50 visits per calendar year80% PPO Provider80% PPO Provider
Retail: (30 day supply)10% Co-Pay for Generic Drugs 20% Co-Pay for Preferred (Formulary) Brand Name Drugs40% Co-Pay for Non-Preferred (Non-Formulary) Brand Drugs
Mail Order: (up to 90 days)10% Co-Pay for Generic Drugs 20% Co-Pay for Preferred (Formulary) Brand Name Drugs40% Co-Pay for Non-Preferred (Non-Formulary) Brand Drugs20% Co-Pay Specialty Pharmacy ProgramCo-Pay Max per prescription $250
Maintenance Medications (specifi c drugs only): No Co-Pay
**Rates for Compliance
1) Incentive Rates apply with completed annual health evaluation. New enrollees have 60 days to complete initial evaluation (Applies to adults over age 18).
2) Incentive rates apply in future years based on compliance with recommended health management program; base rates apply fi rst of month after second annual health evaluation if non-compliant (Applies to adults over age 18).
Compliance will be determined by the personal health score and goal. The score is comprised of fi ve lifestyle risk factors: glucose, LDL cholesterol, triglycerides, blood pressure and smoking. The members ability to improve (or maintain) this score is an indicator of their personal engagement and commitment to health.
The personal health score is calculated using the following criteria:
1) Blood Pressure: 1 point per BP unit above 139/89 (Systolic/Diastolic). A 5-point credit against the IHI score can be earned if both systolic and diastolic blood pressure values are below 140/90.
2) LDL Cholesterol: 1 point per unit above the personal LDL target level of 99, 129 or 159 mg/dl. A 5-point credit against the IHI score can be earned if value is at or below the participants LDL target level.
3) Glucose: 1 point per Glucose unit above 99. A 5-point credit against the IHI score can be earned if glucose is at or below target of 99.
4) Triglycerides: 1 point per 10 Triglyceride units above 149. A 5-point credit against the IHI score can be earned if triglycerides a