Download Delta`s Healthy Rewards Program

Delta’s Healthy
Rewards Program
Administration Services
Helping You Navigate the
Winding Road of Healthcare Reform
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.
Cost Control—Delta manages
plan cost by encouraging
health awareness and
individual responsibility.
Administration Services
I N T R O D U C I N G H E A LT H Y R E W A R D S
Delta Health Systems has designed a new benefit 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 first 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 period’s closure during year one.
• Provide a participant report within four weeks in year
two and beyond.
Important Elements of Healthy Rewards
P E R S O N A L H E A LT H S C O R E
Participants receive a Personal Health Score that is calculated based on:
• Blood Pressure
• Glucose
• Tobacco Use
• LDL Cholesterol
• Triglycerides
H I PA A- C O M P L I A N T G O A L S
The member’s 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.
C U S TO M I ZA B L E P RO G RA M S
Clients 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 annual
screenings and other clinical tests
Customization also includes compliance for specific conditions that utilize evidence-based guidelines.
For example, specific guidelines for diabetics include:
• Eye exam in last 12 months
• LDL test in last 12 months (18–75 yrs. old) (HEDIS)
• HbA1c test in last 12 months
• Lipid profile in last 12 months
• Influenza immunization
Healthy Rewards incents
members to participate by
reducing their contribution
levels—up to 30% of the
benefit value.
Healthy Rewards includes components of TeamCare, Delta’s 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 benefit 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 Management—URAC-accredited programs that involve our specialized team of
doctors and nurses who produce favorable patient outcomes at the lowest possible costs. And, our master’s
degree-level educators develop lifestyle management programs that help members make healthier choices,
thus reducing the incidence of complications and future medical costs.
• Wellness Programs—Support 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 Management—Targets chronic conditions, such as diabetes and asthma; evidence-based guidelines
are used to impact health and measure improvements.
• Maternity Management—Provide education and support to expectant mothers in order to reduce instances
of complications and subsequent high claims costs.
…and more!
Healthy Rewards Plan Example
H OSP ITAL BE N E F I T S
Inpatient and
Outpatient Admissions
Requires use of PPO Network Facilities
100% Benefit at PPO Facilities (no Deductible)
No Benefit at Non-PPO Facilities (except as noted below*)
Emergency Room
$100 ER Co-Pay (Waived if admitted)
Surgi-Centers
100% Benefit at PPO Facilities (no Deductible)
No Benefit at Non-PPO Facilities (except as noted below*)
Skilled Nursing Facility
100% to a maximum of 120 days per stay
Mandatory Centers of Excellence
100% at PPO Facilities
No Benefit at Non-PPO Facilities (except as noted below*)
MEDICAL BENEFITS
Deductible
Requires use of PPO Network Providers
Benefits
Doctor Visits
X-rays and Lab
Ambulance
Surgeon and Related Services
No Deductible
70% Coinsurance for PPO Providers
No Benefit for Non-PPO Providers (except as noted below*)
Chiropractic
Physical Therapy
Speech Therapy
Occupational Therapy
$1,500 calendar year maximum
24 visit maximum
24 visit maximum
24 visit maximum
Hearing Aid and Testing
$800 maximum benefit
Preventive Care, Routine
Physicals and Immunizations
100% Benefit for PPO Providers Only
No Benefit for Non-PPO Providers
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
$5,000 Per Year Maximum Out of Pocket for Individuals
$10,000 Per Year Maximum Out of Pocket for Families
*In the case of an emergency admission to a Non-PPO Hospital, the PPO Percentage rate will continue only until
the doctor verifies that you or your dependent’s 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.
M E N T A L H E A LT H
Inpatient
Inpatient / Residential
30 day maximum per lifetime
100% PPO Facility
Alcohol & Substance Abuse
90% at TARP Contracted Facility
Outpatient
Day Care Program
Office Visit
50 visits per calendar year
80% PPO Provider
80% PPO Provider
PRESCRIPTION DRUGS
Through designated PBM
Generic Drugs mandatory
when available.
DAW (Dispensed as Written
if preauthorized)
Retail: (30 day supply)
10% Co-Pay for Generic Drugs
20% Co-Pay for Preferred (Formulary) Brand Name Drugs
40% 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 Drugs
40% Co-Pay for Non-Preferred (Non-Formulary) Brand Drugs
20% Co-Pay Specialty Pharmacy Program
Co-Pay Max per prescription $250
Maintenance Medications (specific drugs only):
No Co-Pay
2 T I E R M O N T H LY C O N T R I B U T I O N S
Sample Contributions
Single Contribution
Single Incentive Contribution**
$100
$50
Family Contribution
Family Incentive Contribution**
January 2013 to December 2013
$200
$100
The personal health score is calculated using the following criteria:
**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 first 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 five lifestyle risk factors: glucose,
LDL cholesterol, triglycerides, blood pressure and smoking. The
member’s ability to improve (or maintain) this score is an indicator
of their personal engagement and commitment to health.
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 participant’s
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 are at or below target of 149.
5) Tobacco Use: 40 points for using tobacco.
Built to stand the test of time, Delta Health Systems has
delivered as promised to its clients for more than 45 years.
By partnering with Delta, you can expect:
Self-funded health plan expertise that transcends
many different vendors—we have the flexibility to
customize a plan that is right for you.
Complete transparency of costs—one administrative
fee and no “nickel and diming” for support/
troubleshooting calls.
Total accountability for adhering to the highest
of standards—we are an SSAE 16 audit-approved
business.
Cost control as a result of strong network
relationships and TeamCare, our population
health management solution.
“ D E L I V E R A S P R O M I S E D”
Settle all accounts promptly and accurately
Be a knowledgeable intermediary
Provide cost-effective benefit plans
Administration Services
S N A P S H O T—
D E LT A H E A LT H S Y S T E M S
• Founded in 1968
• Independent and privately held
• More than 250 employees
• Offices in Stockton, CA; Fresno, CA;
and Salt Lake City, UT
To find out more about the many
advantages Delta has to offer, contact
Delta Health Systems at 877.391.9597.
www.deltahealthsystems.com