Smart Choices/Healthy Rewards Program
Your choice to participate in the Smart Choices/Healthy Rewards Program is voluntary.
If you complete the Smart Choices action steps, you become eligible to earn Healthy Rewards.
Smart Choices/Healthy Rewards is a health promotion program designed to bring high quality care to Participants and, at the same time, make care more affordable for everyone. All employees and their Spouse and Domestic Partner enrolled in the Blue Cross Advantage Network (APPO) or Kaiser plan options are eligible to sign up for the Smart Choices/Healthy Rewards program.
When you make certain actions to learn about and improve your health, you become eligible to earn Healthy Rewards, including an increased hour bank for Bargained Employees and the ability to earn additional funding for health care expenses (contributions will be made to a Health Reimbursement Arrangement account).
Step 1 for Blue Cross Advantage Network/Smart Choice (APPO) Participants: Get a Biometric Health Screening or Complete a Health Risk Questionnaire
As part of the Smart Choices Program, you (and your covered Spouse/Domestic Partner) need to complete biometric health screening or complete a Health Risk Questionnaire by the annual deadline. Please see your open enrollment packet, or contact the Fund Office for more information on the deadline.
Biometric Health Screening: This screening is provided at no cost to you. The screening will collect a number of biometric measurements, such as height, weight, blood pressure, as well as a blood specimen. It can help identify your potential health risk factors that can lead to chronic illness. Knowing this information and then working with your doctor to improve your health can help you live a healthier and more productive life. The requirement to complete a biometric health screening does not apply to children.
You can get your biometric health screening through the Wellness Program/Biometric Testing vendor listed on the Quick Reference Chart or through your doctor. If you go to your doctor for your screening, be sure to bring a Physician Results Form. This Physician Results Form is available from the Wellness Program/Biometric Testing vendor listed in the Quick Reference Chart. Your doctor will need to fill it out and send it to the Biometric Testing vendor. Once you complete your screening, you’ll receive the Quest Diagnostics Blueprint for Wellness MyTest Profile report. We encourage you to share this with your doctor and determine the best course of action for your health.
Quest Diagnostics will notify the Fund Office that you successfully completed the action step of the Smart Choices Program by getting a biometric health screening. Your personal health information will not be shared with the Trust Fund, Trustees, Union, or Your Employer – only the fact that You (and Your covered Spouse/Domestic Partner) completed a screening will be communicated to the Fund Office. The Trustees and Trust Fund may receive aggregate data about the group, in order to help with benefit planning, but will not receive individual information on screening results.
Health Risk Questionnaire: As an alternative to biometric testing through Quest Diagnostics, you and your Spouse/Domestic Partner may complete a Health Risk Questionnaire (HRQ). The HRQ is available through the Care Counseling Service and may be completed either online or over the phone (please contact them at the number and website provided in the Quick Reference Chart for more information). Once you’ve completed the HRQ, you will receive a customized action plan to help you succeed in creating a healthier lifestyle. The Care Counseling Service will notify the Fund Office that you have successfully completed the action step of the Smart Choice Program by completing the HRQ. Your personal health information will not be shared with the Trust Fund, Trustees, Union, or Your Employer – only the fact that You (and Your covered Spouse/Domestic Partner) completed a HRQ will be communicated to the Fund Office. The Trustees and Trust Fund may receive aggregate data about the group, in order to help with benefit planning, but will not receive individual information from HRQs.
Step 1 For Kaiser/Smart Choice (HM) Participants: Complete a Health Risk Questionnaire, Biometric Screening, Online Health Improvement Course or in-person Health Education Class
As part of the Smart Choices Program, you (and your covered Spouse/Domestic Partner) need to complete a required action step by the annual deadline. You may choose from the following available action steps:
Health Risk Questionnaire: The Health Risk Questionnaire is available through Kaiser, please contact them at the number provided in the Quick Reference Chart for more information on the HRQ and the deadline. To complete the Health Risk Questionnaire, please visit www.kp.org or healthy.kaiserpermanente.org/northern-california and go to the tab entitled “Health and Wellness,” then go to “Programs and Classes. Next, click on “Total Health Assessment.” Once you’ve completed the questionnaire, you will need to self-report your completion of this action step to the Fund Office by printing your certificate and mailing it to the Fund Office. From Kaiser you’ll receive a customized action plan to help you succeed in creating a healthier lifestyle.
Biometric Health Screening: Once the requirements of initial eligibility are met by the established deadline, you may maintain eligibility for the Smart Choices/Healthy Rewards program in future years by completing Kaiser’s recommended biometric health screenings within the required timeframes. You can get your biometric health screening through your doctor or through Kaiser. A list of Kaiser Providers offering these Biometric Health Screening services, and more information about the screenings required and the deadlines is available from Kaiser at the phone number listed on the Quick Reference Chart.
Be sure to sign and bring the Kaiser Proof of Biometric Screening Form and the Occupational Health and Safety Services Referral Form (that has been provided to you). If your Spouse/Domestic Partner is covered under Fund benefits, he/she will need a form too. If you need another form, please call the Trust Fund Office.
To schedule a screening with your doctor, call Kaiser at the telephone number listed on the Quick Reference Chart. Be sure to bring the Kaiser Proof of Biometric Screening Form with you. Your doctor will need to fill it out and send it to Kaiser. If you already had your annual screening, simply ask your doctor to complete the Kaiser Proof of Biometric Screening Form, sign it and fax it to Kaiser at the number on the Form.
Watch your mailbox for your results. Kaiser will mail a copy of the results to you, and forward them electronically to your doctor. Kaiser will also send you an email with a link to access your results through your online medical record—all good reasons to keep all contact information current.
Online Health Improvement Course or In-Person Health Education Class: For more information on available courses that may be appropriate for you and your lifestyle, please contact Kaiser at the number provided in the Quick Reference Chart, or visit www.kp.org or healthy.kaiserpermanente.org/northern-california and access the tab entitled “Health and Wellness,” then go to “Programs and Classes.” If you take an online course, Kaiser will report your compliance to the Fund Office. If you take an in-person course, you must have the instructor complete a Health Education Confirmation Form or Certificate, and you must mail the completed form/certificate to the Trust Fund Office.
Confidentiality: Your personal health information will not be shared with the Trust Fund, Trustees, Union, or Your Employer – only the fact that You (and Your covered Spouse/Domestic Partner) completed the Educational Requirement will be communicated to the Fund Office. The Trustees and Trust Fund may receive aggregate data about the group, in order to help with benefit planning, but will not receive individual information on any screening results or HRQs.
Step 2: Earn Healthy Rewards (Bargained Employees)
When you complete the required action steps, you become eligible for the program’s Healthy Rewards including additional contributions to your cash bank and a Health Reimbursement Arrangement (HRA). The Health Reimbursement Arrangement (HRA) is a notional account set up by the Fund that can be used to reimburse eligible employees for a variety of out-of-pocket medical expenses. The HRA is intended to comply with the requirements of IRS Notice 2013-54 and shall be interpreted to accomplish that objective.
- You can bank an additional three months of excess contributions in your cash bank, for up to six months total.
- After reaching that six-month maximum, you can bank up to 20% of contributions in excess of 130 hours per month into a Health Reimbursement Arrangement (HRA). You can use your HRA funds to pay for eligible health care expenses, as explained in more detail below.
|The Rewards||What it is||How it works||Maximum accumulation allowed*|
|First, you’ll receive…||A three-month extension of cash bank accumulations to a maximum of six months.||Hours worked over 130 per month are used to calculate your cash bank dollar amount, up to a maximum amount that will purchase six months of coverage.||You can continue to accumulate dollars in your cash bank until you reach the six month maximum.|
|After the six-month maximum is reached…||Additional amounts will be contributed to an HRA on your behalf.||20% of hours worked over 130 hours per month will be used to calculate the dollar amount to be contributed to your HRA.||The amount you can accumulate in your HRA is unlimited. However, it may only be used for eligible health care expenses.
How Your Health Reimbursement Arrangement (HRA) Works
- HRA contributions are tax-free to you.
- You can use your HRA balance to pay for eligible health care expenses. The federal government determines the types of expenses that are eligible for reimbursement.
- HRA contributions may roll over from year to year. You may use your HRA funds as long as you maintain active hourly eligibility and you are enrolled in the Smart Choices/Healthy Rewards plan.
- Unlike a regular bank account, HRA contributions do not earn interest and can’t be invested.
- You forfeit your HRA balance when your plan eligibility terminates for any reason; however, your HRA balance will be reinstated if you return to covered employment and re-establish plan eligibility within 12 months from the date your eligibility terminated.
|Upon termination of coverage, you have the option to permanently opt out of the HRA. This means that you will forfeit any remaining HRA balance and you will be able to apply for a premium assistance tax credit in a health insurance Marketplace. Whether you qualify for a tax credit will depend upon your eligibility under the rules of the Affordable Care Act. Please note: If you retain any balance in your HRA, you will not be eligible for the tax credit.
A Participant is permitted to permanently opt out of and waive future reimbursements from the HRA at least annually, in a time and manner determined by the Board of Trustees. Upon termination from the Fund, the Participant may opt out of and waive future reimbursements from the HRA. Please note that reinstatement of any HRA balances is not permitted if the Participant has opted out of HRA coverage.
- When you retire, you forfeit your HRA balance at the same time your active eligibility terminates. This is typically one month after your retirement date.
- The HRA has no cash value.
- You may not participate in the HRA unless you are actually enrolled in a group health plan that provides minimum value pursuant to Internal Revenue Code Section 36B(c)(2)(C)(ii). A group health plan provides minimum value if the coverage is at least 60 percent of the actuarial value of a standard plan as determined by the IRS.
- You are permitted to permanently opt out of and waive future reimbursements from the HRA at least annually, in a time and manner determined by the Board of Trustees, and upon termination of coverage under the plan.
In-Network PPO and Out-of-Network Non-PPO Services
Plan Participants may obtain health care services from PPO or Non-PPO providers. Because health care providers are added to and deleted from the PPO networks during the year you should call the network or check their website, or ask the provider to verify their contracted network status before you visit that provider to assure you will be able to receive their discounted price for the services you need.
PPO Provider Services
In-network health care providers have agreements with the Plan’s Preferred Provider Organization (PPO) under which they provide health care services and supplies for a favorable negotiated discount fee for Plan Participants. When a Plan Participant uses the services of a PPO health care provider, the Plan Participant is responsible for paying the applicable copayment or coinsurance on the discounted fees for any medically necessary services or supplies, subject to the Plan’s limitations and exclusions.
For the Blue Cross Network plan, PPO refers to providers that are a member of Anthem’s PPO Network. For the Blue Cross Advantage Network plan, PPO refers to providers that are a member of the Advantage Blue Cross Network (APPO) only; PPO providers that are not part of the APPO network are considered Non-PPO providers for purposes of the Smart Choices/Healthy Rewards Program.
The PPO health care provider generally deals with the Plan directly for any additional amount due. Note that with respect to claims involving any third party payer, including auto insurance, workers’ compensation or other individual insurance or where this Plan may be a secondary payer, the contract between the Health Care Providers and the PPO Network may not require them to adhere to the discounted amount the Plan pays for covered services, and the providers may charge their usual non-discounted fees.
You may also verify if your health care provider is a PPO provider by contacting the PPO at their phone number and website listed on the Quick Reference Chart.
Non-PPO Provider Services
Non-PPO health care providers (also called non-network, out-of-network, and Non-participating providers) generally have no agreements with the Plan and are generally free to set their own charges for the services or supplies they provide (as explained above, for purposes of the Blue Cross Advantage Network plan, PPO providers that are not part of the APPO Network are considered Non-PPO providers, even though the PPO providers may have agreements with the Plan for other healthcare programs). If you have not signed an assignment of benefits, the Plan will reimburse the Plan Participant for the Allowed Charge (as defined in this document) for any medically necessary services or supplies, subject to the Plan’s Deductibles, coinsurance (on non-discounted services), copayments, limitations and exclusions. Plan Participants must submit proof of claim before any such reimbursement will be made.
CAUTION: Non-PPO Health Care Providers may bill you for any balance that may be due in addition to the Allowed Charge amount payable by the Plan, also called balance billing. You can avoid balance billing by using In-Network providers.
Please Note: there is no requirement under this Plan that you designate a primary care physician (PCP) provider. Additionally, you do not need prior authorization to obtain access to an OB/GYN provider.
Services outside of California
Participants who live or are traveling outside of California are able to receive PPO contracted rates when services are received from doctors and hospitals that contract with the PPO network in the area where services are received. It is to your advantage to use PPO contracted doctors and hospitals because your coinsurance percentage will be applied to reduced charges, resulting in lower out-of-pocket expenses to you.
To find a PPO provider outside of California you may contact the PPO at their phone number and website listed on the Quick Reference Chart. If you use a Non-PPO provider when there is a PPO provider within 30 miles, (or a “traditional” provider in 30 miles), covered services will be payable at the Non-PPO level, resulting in greater out-of-pocket expenses to you. Instructions on how to locate a “traditional” provider are on the Quick Reference Chart.
Please note: “Traditional” providers do not participate in the PPO network. However, they have agreed to perform services at special discounted rates for PPO members. You should go to a “Traditional” provider only if there are no PPO providers in your area.
Preferred Provider Organization (PPO)
The Plan’s Preferred Provider Organization (PPO) is a network of Hospitals, Physicians, laboratories and other Health Care Providers who are located within a Service Area and who have agreed to provide health care services and supplies for favorable negotiated discount fees applicable only to Plan Participants.
If you receive medically necessary services or supplies from a PPO Provider you will pay less out-of-pocket than if you received those medically necessary services or supplies from a Health Care Provider who is not a PPO Provider; and the PPO Provider has agreed to accept the Plan’s payment plus any applicable out-of-pocket amount that you are responsible for paying as payment in full.
Blue Cross Advantage Network/Smart Choices (APPO) for Active Employees
At open enrollment, you have the opportunity to choose from four plan options, and may choose to enroll in one of two fully insured HMO plan options, or one of two Indemnity plan options with the Blue Cross Network. If you choose the Blue Cross Advantage Network plan, you will successfully avoid the $1,000 deductible (that is, you will have no deductible) when you and all your covered family members must use Anthem Blue Cross “Advantage Network” PPO (APPO) Providers.
Please Note: Most Sutter-affiliated physicians, hospitals and outpatient providers are not a part of the APPO network (even though they may be part of the larger PPO Network). Be sure to verify your provider’s participation in the APPO network through the Anthem Blue Cross website listed on the Quick Reference Chart or by calling the Fund Office. If you use a non-Advantage provider, Non-PPO Provider coverage will apply.
Directories of Network Providers
You are able to access the network of PPO and APPO providers by going to www.anthem.com. Please refer to the Quick Reference Chart for more information. If you would like a hard copy of the directory of PPO or APPO providers, call the Trust Fund Office. There is no cost to you for the provider directory. If you lose or misplace your Directory, you can obtain another, at no cost, by calling the Trust Fund Office at the telephone number shown in the Quick Reference Chart.
Physicians and Health Care Providers who participate in the Plan’s Networks are added and deleted during the year. It is best if you ask your health care provider if they are still participating with the PPO or APPO or contact the network each time BEFORE you seek services or contact the PPO at their telephone number or website shown on the Quick Reference Chart.
Nondiscrimination in Health Care
In accordance with the Affordable Care Act, to the extent an item or service is a covered benefit under the Plan, and consistent with reasonable medical management techniques with respect to the frequency, method, treatment or setting for an item or service, the Plan will not discriminate with respect to participation under the Plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. The Plan is not required to contract with any health care provider willing to abide by the terms and conditions for participation established by the plan. The Plan is permitted to establish varying reimbursement rates based on quality or performance measures.
- Links to additional Plan information:
- “No Choice” (Special Reimbursement) Provisions
- Prior Authorization (Pre-service) Review
- Concurrent (Continued Stay) Review
- Retrospective (post-service) Review
- Appealing a UM Determination (Appeals Process)
- If You Do Not Comply With Requirements or Disregard the Decision
- Maximum Allowable Charges Apply for Certain Surgical Procedures
- Inpatient Hospital Procedures
- Exceptions Process