SAN MATEO COUNTY WELLNESS DIVIDEND PROGRAM 2017

Transcription

1 SAN MATEO COUNTY WELLNESS DIVIDEND PROGRAM 2017 February 2017 Dear County Employee: San Mateo County has provided onsite wellness screenings and rewards for many years. Through the work of the labor-management Benefits Committee, the Physician Option was introduced last year. This alternative option can be done instead of attending a County onsite Wellness Screening, and enable an employee to remain eligible for financial incentives. This screening option will again be available in You can now schedule a visit with your doctor or health care provider to get updated lab testing and medical results done. Your health care provider is asked to report your most current test results and medical information on a specific Physician Submittal Form. The document is to be completed and certified by your doctor and given back to you. You are fully responsible for sending the completed Physician Submittal Form to BaySport, the County s wellness vendor. You can send it in one of numerous ways, as explained on the attached cover sheet. Keep a copy for your records. Deadline is June 30, Please do not return the Physician Submittal Form to the County. The County does not see the Physician Submittal Form. You first give it to your doctor, and then you give the completed/signed form to BaySport. Additionally, you will review and sign the required Program Disclosure/Release statement; it limits who can view your medical information thereafter. You will note that the County and Court, its supervisors and management staff are not on that list. New for 2017 is an additional notice with detailed information on how your data is being secured. This is to comply with new regulations to protect you. This notice is informational only. As always, this is a completely voluntary program. It is your responsibility to ensure that your Employee Coversheet, the signed Program Disclosure / Release Statement and the completed / certified Physician Submittal Form are sent to BaySport on or before June 30, THE REQUIRED DOCUMENT IS A TOTAL OF THREE PAGES. For more information about this year s Wellness Dividends Program, please visit our website: Rob Davenport Employee Wellness Program

2 NOTICE REGARDING WELLNESS PROGRAM The San Mateo County Wellness Program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or HRA that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for Glucose, HbA1C, Cholesterol, HDL & LDL Cholesterol and Triglycerides, all risk markers for diabetes, heart disease and metabolic syndrome. You are not required to complete the HRA or to participate in the blood test or other medical examinations. However, employees who choose to participate in the wellness program will receive an incentive of $500 cash for completing both the online health assessment and biometric screening. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive $500 cash. Additional incentives in the form of nominal gifts may be available for employees who participate in certain health-related activities including health coaching, walking program or various health challenges or achieve certain health outcomes. If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting Rob Davenport at (650) The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as health coaching, chronic condition management, and/or weight management. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the County and the vendor it uses to administer the wellness program, Baysport, may use aggregate information Baysport collects to design a program based on identified health risks in the workplace, Baysport will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment. Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are the Baysport screening technicians and/or independent contracted health coaches in order to provide you with services under the wellness program. To ensure your health information is kept private and confidential form the County, Baysport has agreed to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic protected health information (EPHI) associated with the wellness screening they create, receive, maintain, or transmit. Baysport has also agreed to conform to generally accepted system security principles and the requirements of the final HIPAA rule pertaining to the security of health information. Baysport has further agreed to ensure that any agent to whom it provides EPHI, including a subcontractor, agrees to implement reasonable and appropriate safeguards to protect such EPHI. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Rob Davenport at (650)

3 SAN MATEO COUNTY WELLNESS DIVIDENDS PROGRAM 2017 EMPLOYEE COVERSHEET (PAGE 1 of 3) Instructions: 1) Complete the Employee Coversheet with all contact and transmittal information as requested (page 1). 2) Sign the Program Disclosure / Release Statement (page 2). 3) Include the completed / certified Physician Submittal Form completed by your doctor (page 3). Note: If your doctor has attached a copy of the results instead of writing the numbers on the Physician Submittal Form, include your doctor s attached copy to the packet for a total of four pages in length. 4) Send your packet (1. CoverSheet 2. Program Disclosure/Release 3. Physician Submittal Form) to BaySport on or before June 30, Keep a copy for your records. Choose one of the following methods to submit to BaySport: By SCAN the packet and send it to smcgov@baysport.com By FAX: TRANSMIT the packet to BaySport at (408) By US Mail: MAIL the packet to: BaySport, Inc. Attn: SMCo Wellness, Los Gatos Blvd, Suite 101, Los Gatos, CA Emp Name Emp ID BaySport Packet: Page 1 of 3 o The envelope must be postmarked no later than June 30, It will require additional postage. Hand-Deliver your packet to BaySport: You can drop it off at the check-in desk at any County Wellness Screening scheduled between February 1 and June 30, 2017 or at the BaySport office at BayClub-Redwood Shores, 200 Redwood Shores Parkway, Redwood City during normal business hours (M-F, 8am - 4pm). Submit your packet in a sealed envelope; and be certain that your name and County Employee ID number are written (clear and legible) on the front of the envelope. If delivering at a County Wellness Screening, it should be initialed and dated by a BaySport employee in your presence. If delivering to the BaySport office, it should be hand-stamped by a BaySport employee. Do not leave your packet on an unattended table or next to a locked door after hours as BaySport cannot guarantee receipt. 5) Upon receipt, the packet will be electronically date stamped, and BaySport will send a confirmation to your address within 10 business days of your transmittal indicating that it has received all three pages, or indicating that the packet is incomplete and must be re-submitted. TO: BAYSPORT (choose one): FAX: (408) SMCGOV@BAYSPORT.COM U.S.MAIL: BaySport, Inc. ATTN: SMCo Wellness, Los Gatos Blvd, Suite 101, Los Gatos, CA DROP OFF: County Wellness Screening BaySport@BayClub, 200 Redwood Shores Pkwy, Redwood City FROM (print clearly): NAME EMPLOYEE ID COUNTY/COURT PHONE NUMBER: COUNTY/COURT ADDRESS If NO County/Court address, provide an alternate address YOUR FAX NUMBER (if sent by fax): Physician Option Packet is THREE PAGES. This and all attachments to it are for the sole use of the intended recipients and may contain proprietary information and trade secrets of Alliant Insurance Services, Inc. and its subsidiaries. This may also contain information which is confidential or which is protected from disclosure by privilege. Any unauthorized use, disclosure or distribution of this and its attachments is prohibited. If you are not the intended recipient, let us know by reply and then erase and destroy all electronic or other copies of this message.

4 PROGRAM DISCLOSURE / RELEASE STATEMENT (PAGE 2 of 3) Emp Name Emp ID BaySport Packet: Page 2 of 3 The Voluntary Wellness Dividends Program has two components: a Wellness Screening and an online health assessment. When these two action steps are completed by the advertised deadline, a benefits-eligible County or Court employee (who is enrolled in either a County Blue Shield health plan or a County Kaiser health plan) becomes eligible to receive a Wellness Dividend, payable in November. As a benefits-eligible County or Court employee, you can participate in the Wellness Screening Program at an onsite Countysponsored clinic OR by visiting your doctor or health care provider. The Wellness Screening Program utilizes independent contractors to provide wellness screening services, specific educational follow-up, health coaching, program evaluation and employee health data management. The following independent contractors provide one or more of these services: BaySport, Nurse Health Counselor (and his/her designees), Kaiser Permanente s Southbay Worksite Wellness, Alliant Insurance Services, Inc. BaySport is responsible for retaining the clinic information provided by your doctor or health care provider in a secure and confidential manner. Contact BaySport at in the future with any questions about your health information. The Nurse Health Counselor and Kaiser Permanente s Southbay Worksite Wellness are authorized to have access to your personal health information and are responsible for reviewing results, identifying and contacting moderate and high risk individuals for follow-up and individual health coaching services. Health coaching services are offered by invitation only, and there is an additional financial incentive for those who participate and complete the program. Alliant Insurance Services, Inc. provides technical expertise to analyze employee health data for workforce health reports and trends. Individual names are removed from health information data. MODERATE OR HIGH RISK FOLLOW-UP If the test results or medical information noted on your Physician Submittal Form are outside of the normal range, you will be contacted by a Nurse Health Counselor by telephone or electronic mail for additional follow-up. This may include but is not limited to: encouraging further medical evaluation by your personal doctor, answering questions, providing additional medical information regarding your health results and/or inviting you to participate in a Health Counseling program to reduce your health risk(s). If you are a Kaiser member, you may be referred to Kaiser Permanente s Southbay Worksite Wellness for additional follow-up with your Kaiser provider and/or participation in their services, including but not limited to health counseling. Your participation in the program is voluntary. As a San Mateo County or Court employee and voluntary participant in the Wellness Dividends Program, I explicitly understand and acknowledge that neither the County nor any of its contractors listed above are providing health care services. Instead, I am being given general information intended to help me increase my awareness of risk factors that may or may not adversely affect my personal health and longevity. Personal health information and test results will be shared between the independent contractor(s) listed above solely for the purpose of additional and specific follow-up, counseling services and targeted educational outreach and program evaluation. Statistical analysis of any health information will be done in aggregate and will not utilize any personal identifying information. BaySport will share my full name and my Employee ID number with the County for the sole purpose of documenting that I have submitted a complete and certified Physician Submittal Form to them on or before the posted deadline. I have read, understand and accept the above information and I agree to participate in the Wellness Dividends Program. Print your name clearly: Signature: Date:

5 WELLNESS SCREENING PHYSICIAN SUBMITTAL FORM (PAGE 3 of 3) Employee: Give this form and accompanying letter to your health care provider to complete and return to you (employee). Inform your doctor or health care provider if you would like to include prior test results (optional). You (employee) are responsible for sending this completed/certified document to BaySport using the Employee Coversheet. Download the Employee Coversheet at: DO NOT send the completed/certified document to the County. EMPLOYEE: You fill this form out down to the heading below, Health Care Provider. Employee Name: Contact Phone: (for provider to contact you when form is complete) Employee ID: DOB: SEX: M F Medical History (Please check any or all that apply) Condition Personal History of: Currently Taking Medication for: Cardiovascular Disease -Prior to age 55 Diabetes Type I/ Type II (Adult Onset) High Blood Pressure (> 140/90) High Total Cholesterol (>240) Smoking Status: Never Current Vape/E-cig Former-Year that you quit (i.e. 1996) HEALTH CARE PROVIDER - Please fill in the following results, or attach a copy of results, sign, and return to patient: SCREENING INDICATOR Current Results (Required for $500 employee incentive) Prior Results (Optional) Prior Results (Optional) Height (inches) Weight (pounds) Resting Blood Pressure (mm Hg) Total Cholesterol (mg/dl) HDL Cholesterol (mg/dl) LDL Cholesterol (mg/dl) Triglyceride (mg/dl) Glucose (mg/dl) HbA1C (mg/dl) (if applicable) HEALTH CARE PROVIDER Certification: I certify that the results as written here (or attached) are true and correct. I certify that all clinical tests are current according to the US Preventive Services Task Force recommendations based on the patient s medical conditions or medication(s) and/or medical group practice protocols. Name of Health Care Provider Signature of Provider or Authorized Representative Address Phone Date Provider Stamp Required Here OR Write California State License Number