2008 Request for Health Enhancement Assistance (HEA)

Transcription

1 2008 Request for Health Enhancement Assistance (HEA) Instructions (See page 2 of form. Note: RECEIPT MUST BE SUBMITTED FOR REIMBURSEMENT) Section A Employee information (Please type or print in ink all information) Last name First name and M.I. Social security # OR Aetna ID# (if applicable) Home address Daytime Phone Number address Section B Pre-Approved Programs Refer to Q&A for a List of Qualified, Pre-Approved Programs Section C Other Programs Requiring Employee Health Management (EHM) Approval START DATE END DATE Organized Group Activity (submit claims only after 6 months minimum participation) Nutritional Counseling (minimum 70% completion) Smoking Cessation (minimum 70% completion) Weight Management (minimum 70% completion; program cost only no food supplements) If your program is not listed in question number 7 of the Q&A, it requires approval by EHM. See instructions, number 4. I am considering participating in the following program. I understand that this program has not been pre-approved and must be submitted to Employee Health Management (EHM) for approval prior to filing for reimbursement. START DATE END DATE Program Name: Brief Description of Program: Program Receipt Requirements Program receipts must show the total amount paid within the time period 1/1/07 through 12/31/07. Membership/Program agreements must state contract start date and end date with monthly amount paid. Proof must be provided for each payment if dues are paid on a monthly basis. Certification Statement I certify that all information I have provided is correct and that I have actively participated and met the minimal adherence criteria as stated above. I understand that failure to complete this form truthfully will be considered fraud and will lead to disciplinary action including possible termination of employment. Employee signature Date Return to: Aetna P.O. Box 4000 Richmond, KY Fax to: Phone: HEA Claim Form Page 1 (Rev. 12/07)

2 2008 Request for Health Enhancement Assistance (HEA) Instructions: Complete as specified below and return to Aetna. 1. Please review the HEA Q&A for the program guidelines prior to joining a health enhancement program. All benefits eligible employees are eligible to file ONE HEA claim per year. Note that all expenses must be incurred on or after January 1, Your request for reimbursement must be received no later than April 30, 2009 to receive reimbursement for the 2008 year. Costs must be incurred in the year for which you are applying for reimbursement, and only one reimbursement is allowed per calendar year*. For example: Fitness facility start date October 2007; completion date March 2008; will only be reimbursed for one calendar year (2008). No additional reimbursements will be allowed for *Smoking Cessation programs and products are exempt from this requirement. See attached Q&A for more details. 2. Complete Section A. 3. Complete the Program Information (Section B) including the start and end dates. 4. Programs requiring EHM approval, complete Section C. Programs Requiring EHM Approval, complete Section C. For program approval submit this form with Section A completed and program information (brochures) describing class topic, length of program, staff qualifications and any other relevant information to EHM at the address listed below. EHM will review the program and you will be notified in writing whether or not your participation is approved for reimbursement. In order to receive a reimbursement you must submit this form to Aetna (see #5) after six months or 70% completion of the program. GlaxoSmithKline Employee Health Management (EHM) 1250 South Collegeville Road, UP5006 Collegeville, PA Attn: Ellen Sharkoski 5. SEND THE FORM AND YOUR ITEMIZED PROGRAM RECEIPT TO: AETNA, P.O. BOX 4000, RICHMOND, KY DO NOT SEND FORMS TO EHM UNLESS YOU ARE REQUESTING APPROVAL FOR A PROGRAM THAT HAS NOT BEEN PRE-APPROVED. 6. Reimbursement will be processed by Aetna and mailed with a separate explanation of payment. Denial of Reimbursement Your request for reimbursement has been denied due to the following reason(s): No itemized receipt attached A claim has been previously submitted and paid in the current calendar year Program or service is not pre-approved (see approval section B & C) or is not an eligible expense Applicant is not benefits eligible Insufficient receipt Did not satisfy 6 month or 70% completion requirement Other 2008 HEA Claim Form Page 2 (Rev. 12/07)

3 Health Enhancement Assistance Questions and Answers 1. What is Health Enhancement Assistance? Health Enhancement Assistance (HEA) is a part of the GSK Total Reward program that encourages employees to take an active role in managing their health. By being an active participant in the process of becoming healthier, you are able to establish meaningful health goals for yourself and work to meet these goals. GSK is pleased to partner with you in your efforts of obtaining and managing your health in order for you to feel better and enjoy life more. In this effort you help to productively work for the success of the company as well as reduce excessive health care costs for which the company pays. 2. What is the Health Enhancement Assistance benefit? The assistance program provides reimbursement for certain eligible prevention and wellness activities such as physical activity programs, nutrition and weight management and healthy babies. Approved activities must comply with medical necessity IRS definitions and ERISA plan guidelines. The expenses must be primarily to alleviate or prevent a physical or mental condition or illness. Expenses considered merely beneficial to general health are not approved expenses. Examples of non-covered expenses are vitamins, food/supplements, vacations, leisure or social activities and any service rendered for cosmetic purposes. 3. Who is eligible for Health Enhancement Assistance? Employees who are eligible to receive medical benefits from GlaxoSmithKline are eligible for Health Enhancement Assistance, unless you are on an unpaid leave of absence. Once you return to active employment with GSK, you will again be eligible to participate in the HEA. Health Enhancement Assistance is not available to spouses, dependents, or retirees. 4. How am I reimbursed for eligible expenses? Health Enhancement Assistance rewards you by paying for a portion of your expense for qualifying programs for organized exercise, weight management, evidence-based smoking cessation, and nutritional counseling by a Registered Dietitian. After meeting certain participation criteria, you may apply for reimbursement once per calendar year. You may include more than one program, but they must be submitted together only once per year for a maximum payment of $100. Evidence-based smoking cessation programs and products are exempt from this limit. 5. How are smoking cessation programs and products covered under the HEA? In support of the CEO Cancer Gold accreditation, the GSK HEA will reimburse all eligible evidence-based smoking cessation programs without being subject to the $100 annual maximum. As a reminder, employees can order GSK smoking cessation products through the GSK Employee Store by calling (215) For a complete price list and ordering information, go to the Franklin Plaza Community on mygsk. The Employee Store Catalog can be found on the left side toolbar under FP Community Links.

4 6. What is the CEO Cancer Gold Standard? GSK preventive health programs and services, including the HEA, are designed to educate employees about prevention, early detection, compliance, risk reduction and practicing healthy behaviors. GSK is proud to be recognized as an accredited CEO Cancer Gold Standard company. This designation acknowledges GSK s efforts aimed specifically at cancer risk reduction, prevention and for supporting employees to live tobacco-free. You are encouraged to visit to learn more about this GSK initiative. 7. How can I be sure that the program in which I participate is eligible for reimbursement? A summary of the guidelines: Organized Group Activity Programs: Your exercise program must include a health history questionnaire and trained staff. Approved programs: GSK Fitness Centers and sponsored internal programs, commercial fitness facilities, personal training, yoga, TaiChi, Pilates and meditation. (Country club memberships, programs to improve skills, such as golf or tennis lessons, and home fitness equipment are not eligible for reimbursement.) Nutrition Counseling: All nutrition counseling programs will be approved as long as a Registered Dietitian provides the counseling. Information on locating a Registered Dietitian in your area can be obtained by calling the American Dietetic Association at Physician-prescribed nutritional counseling for chronic disease may be included but will be reviewed case by case (must include prescription with receipt). Smoking Cessation: To assure that your program is safe and effective, Employee Health Management (EHM) has approved a number of evidence-based smoking cessation programs and over the counter products. Approved programs: Hospital approved smoking cessation programs, Nicoderm Committed Quitters, Nicorette Committed Quitters, Commit Committed Quitters, onsite smoking cessation programs, and Smokeless. The $100 annual maximum will not apply towards evidence-based smoking cessation programs and products in support of the CEO Cancer Gold Standard accreditation. Weight Management: To assure that your program is safe and effective, Employee Health Management (EHM) has pre-approved a number of programs. Approved Programs: Better Prepared Weight Management, Jenny Craig, Weight Watchers, Curves, Physician s Weight Loss, The Diet Center, LA Weight Loss and many GSK sponsored programs, such as Changing Your Relationship with Food, are approved. If your program is not on the list, it must be approved by and meet established EHM criteria prior to joining the program to qualify for reimbursement. For programs requiring EHM approval, submit your completed HEA form and program information describing class topic, length of program, staff qualifications and any other relevant information to EHM at the address listed below. EHM will review the program and you will be notified whether or not your participation is approved for reimbursement. GlaxoSmithKline Employee Health Management (EHM) 1250 South Collegeville Road, UP5006 Collegeville, PA Attn: Ellen Sharkoski

5 8. What is the participation criteria that must be met in order to receive reimbursement? Minimum participation levels have been established in order to receive reimbursement through Health Enhancement Assistance. These levels are as follows: Organized Group Activity Programs - be a participant (once per week) for 6 months or more. Weight Management, Smoking Cessation, and Nutrition Counseling - participate in 70% or more of the sessions. 9. How often can I be reimbursed? Costs must be incurred in the calendar year for which you are applying for reimbursement, and only one reimbursement allowed per calendar year. For example: Fitness facility start date is October 2007; completion date March will only be reimbursed for one calendar year (2008). No additional reimbursements will be allowed for Evidence-based smoking cessation products and programs are exempt from this limit and allow for more frequent submissions, but still require itemized receipts and completion of HEA claim forms. 10. Will I have to provide proof of participation in order to receive reimbursement? Yes Signing the Request for Health Enhancement Assistance form attests that the minimum participation level has been met. However, proof of payment in the form of an itemized receipt must also be provided. 11. What type of itemized receipt do I need? Program receipt requirements are as follows: Program receipts must indicate dates of participation and show the total amount paid for the time period of January December If providing credit card or bank statements as your receipt, they must be itemized and submitted with dates for each month. Statements with one total lump sum are not considered a valid receipt and will be returned for itemization. Membership/program agreements must state contract start date and end date with monthly and total amount paid. Proof must be provided for each payment if dues are paid on a monthly basis. Itemized store receipts for evidence-based smoking cessation products. 12. Do I need to submit a receipt even if I have a rolling lifetime membership? Yes. An annual itemized receipt is required for every request for reimbursement. 13. How will I measure 70% participation in a program if there is no fixed completion date? Some programs such as Weight Watchers may not have a set completion date. In this case, you must participate in 70% of the sessions for which you are requesting reimbursement. For example, you may participate in an ongoing Weight Watchers program at a cost of $10 per week. At the end of 18 weeks you will have incurred expenses of $180 and may choose to file for reimbursement at this time even though you will continue to attend the program. In this example, 70% participation would be attendance at 13 of the 18 sessions.

6 14. Will I be eligible for reimbursement for an organized exercise program if I have a family membership at a facility? Family memberships will be eligible for reimbursement provided the facility meets the requirements stated above and you complete the minimum level of six months of active participation. Health Enhancement Assistance is not available for individual spouse or dependent memberships. 15. What is the deadline for filing reimbursement? The deadline for filing for reimbursement is April 30th of the following calendar year. For example, your 2008 claim for reimbursement must be received by no later than April 30, 2009, for costs incurred January 1, 2008 through December 31, Who will reimburse HEA claims? The claims administrator for all HEA claims is Aetna and you will receive a separate check mailed to your home address. Participation in a GSK medical plan is not a requirement; however, you must be an actively employed, benefits eligible GSK employee to participate in the program. 17. Where can I get a claim form to submit for reimbursement? The HEA form can be obtained at mygsk / Work and Life / Health & Wellbeing / Home Community / Health Enhancement Assistance. The Health & Wellbeing site also provides more information regarding other programs that are available to help you maintain a healthy lifestyle. The form is also available at the following sites: Aetna - GSK HR Portal - If you are unable to access the form online, please contact the GSK HR Service Centre at myGSKHR ( ). 18. Where do I submit my claim form and program receipt? Attach your program receipt to a completed HEA Request form and return to: Aetna P.O. Box 4000 Richmond, KY Or you may fax your claim form and program receipt to Aetna at Who can I call with further questions on claims? You can call Aetna at , or for specific program approval, Ellen Sharkoski at Ellen.E.Sharkoski@gsk.com.