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PEBTF Get Healthy Program

The Get Healthy Program for the American Federation of State, County and Municipal Employees (AFSCME) and State College & University Professional Association (SCUPA) members offers a variety of wellness opportunities as part of the Pennsylvania Employees Benefit Trust Fund's (PEBTF) commitment to promote and support healthy lifestyles.

The goals of Get Healthy are:

  • Inform you and your family about your health and available health care resources
  • Actively engage you and your family in the management of your health
  • Help you and your family lead healthier and more productive lives

FREQUENTLY ASKED QUESTIONS

How do I get started?

Who is eligible for Get Healthy?

Are my dependents eligible to participate?

Will new hires be eligible for Get Healthy?

Who completes the HRA?

Will my employer be advised of this information?>

What is a health coach?

If I am contacted by a health coach, is my participation in any program mandatory?

What is the amount of the Healthy Incentive?

If a member is assigned to Health Management and is asked to take a smoking cessation class (or any other type of program) in order to continue receiving the Healthy Incentive, who pays for the program?

If a member is participating but retires in the midst of the contract period, would he/she still get the Healthy Incentive in retirement?

Who decides if continuing chiropractic care is "medically necessary"?

If verification of participation is required in the form of a doctor completing a form, and he/she charges a fee, who pays the fee?

What gives the PEBTF (or Highmark or Intracorp) the right to analyze your claims data and call you anyway, if you have chosen not to participate?

Is it possible for a PEBTF representative to visit the campus to explain this program in detail and answer all questions?

Who are the vendors involved in the PEBTF's Get Healthy Program and what are their roles?

When I completed the HRA, I received a report that indicated that I am "healthy." I have now received a letter stating that I have been categorized as "chronic." How did this happen?

I don't have the chronic condition that Intracorp/Highmark tells me I have. What makes them think I have this condition?

If I really don't have this condition, what do I do to get my risk status changed?

What is the process for changing my risk status? Once the health coach agrees that I should not be in the "chronic" category, how is that change communicated so that I will know what I need to do to continue the waiver?

I still don't think I have this condition but the health coach says that my claims show that I do. What should I do now?

My health risk assessment (HRA) said that I was "healthy." When I got my participation letter from Get Healthy, it said I was "at risk." I have never submitted any claims, so how did I end up in this category?

When I called Intracorp to tell them that I didn't think I had this condition, they told me to contact my HR office. They said my HR office should tell the PEBTF that I should be in another risk category. Is that correct?

Last year I got a letter from Intracorp asking me to participate in a diabetes program. I told them I did not have diabetes and they said they would remove me from their mailing file. This year, my HRA said I am "healthy" but I was notified that I am "chronic" and received another letter from Intracorp telling me I have diabetes. How did this happen?

I got a letter that says I am "chronic" but it doesn't say what I am "chronic" for. Why can't it be more specific?

Isn't it a violation of confidentiality and the privacy laws to give our health information to vendors like Highmark, Intracorp and Gordian?

How do I get started?

  • Go to www.pebtf.org and click on the Get Healthy logo
  • Enter your Social Security number and birth date
  • You will be directed to Highmark or Intracorp
  • Highmark members must log in
  • Click on "Health Risk Assessment"

Who is eligible for Get Healthy?
All members in any PEBTF medical plan.

Are my dependents eligible to participate?
Yes. All employees and covered dependents are eligible to participate. All employees and spouses are encouraged to complete the HRA.

Will new hires be eligible for Get Healthy?
Members hired after April 1, 2009, will be eligible for Health Management and Overweight and Obesity Management programs only. New hires will not be eligible to complete an HRA until another HRA opportunity is announced. New hires will not be eligible for the Healthy Incentive since they will not have the opportunity to complete an HRA at this time.

Who completes the HRA?
All employees and spouses should complete the HRA (must complete in order to get the Healthy Incentive).

Will my employer be advised of this information?
No. All of your health information will be (and always has been) held in strict confidentiality. Your employer will never receive any information about your health status.

What is a health coach?
A health coach is a nurse who:

  • Works with you and your physician (with your approval) to develop an individualized program
  • Recommends targeted health goals, provides educational materials and answers any questions regarding your condition and/or your doctor's orders
  • Provides information to ensure that your treatment follows evidence-based practice guidelines

If I am contacted by a health coach, is my participation in any program mandatory?
No. Participation is voluntary. However, there is a financial reward for participation.

What is the amount of the Healthy Incentive?
If you were hired before Aug. 1, 2005, your 0.5% contribution will be waived for the first six-month period. If you were hired on or after Aug. 1, 2003, you will enjoy a 0.5% reduction in your premium for the first six-month period.

If a member is assigned to Health Management and is asked to take a smoking cessation class (or any other type of program) in order to continue receiving the Healthy Incentive, who pays for the program?
The employee would pay, although the intention is to have as many programs as possible online so there would be minimal expense to the employee.

If a member is participating but retires in the midst of the contract period, would he/she still get the Healthy Incentive in retirement?
No. The Healthy Incentive is for active employees only.

Who decides if continuing chiropractic care is "medically necessary"?
This part of the program has not changed from how it is currently administered. The medical plan the employee is enrolled in will indicate the number of visits the patient would be entitled to, and would notify the provider once the patient is close to reaching the specified number of visits. The provider is required to submit a treatment plan, which is reviewed by the medical plan (i.e., PPO or HMO), and they will determine if the patient should be entitled to additional visits and notify either "yes" or "no."

If verification of participation is required in the form of a doctor completing a form, and he/she charges a fee, who pays the fee?
It is highly unlikely that a provider will be required to complete a form; but if this did happen, the employee would be responsible.

What gives the PEBTF (or Highmark or Intracorp) the right to analyze your claims data and call you anyway, if you have chosen not to participate?
Again, this practice has been in effect since 2003 - Intracorp has been managing the disease management program, which is now being expanded. This is a voluntary program, and if the employee or family members are contacted for potential case management, they can indicate that they do not want to participate and have their name removed from participation. They should not be contacted after that.

Is it possible for a PEBTF representative to visit the campus to explain this program in detail and answer all questions?
No. Statewide programs were set up to cover the largest area possible with the least amount of travel time for employees. The closest statewide programs to California were in downtown Pittsburgh - this is why we offered our own meetings.

Who are the vendors involved in the PEBTF's Get Healthy Program and what are their roles?
The PEBTF, as a group health plan, has contracted with other companies (business associates) to assist in the administration of members' health benefits, including the Get Healthy Program. Highmark is a health plan that is available for members in western Pennsylvania. They are providing disease management services for their members as part of the Get Healthy Program. 

Intracorp and its partner, American Healthways, have been administering disease management programs for the PEBTF since 2003. The Get Healthy Program expanded the number of conditions being managed and now provides support for members with one of 14 conditions. Disease management is part of normal health care operations for the PEBTF and, therefore, members may be contacted and asked to participate even if they did not complete an HRA or choose to participate in the Get Healthy Program. Of course, if a member is participating in the Get Healthy Program and also engages with a health coach for disease management, this engagement will qualify the member for a waiver of their health care contribution. The PEBTF uses medical diagnosis codes and procedure codes as well as pharmacy codes to identify potential candidates for disease management. Once a potential candidate has been identified, two years' worth of medical and pharmacy claims is sent to the appropriate vendor for use in narrowing the field and identifying actual candidates.

Gordian Health Solutions Inc. is a wellness and disease management vendor and is also a business associate of the PEBTF. Gordian is providing services for the healthy and "at risk" individuals who are participating in the Get Healthy Program. In addition, Gordian wellness programs are available for active employees and annuitants who retired on or after July 1, 2004 even if the individual did not participate in the Get Healthy Program. The Gordian wellness programs are available telephonically and online at no charge to the employee.

When I completed the HRA, I received a report that indicated that I am "healthy." I have now received a letter stating that I have been categorized as "chronic." How did this happen?
The HRA was just one phase of the identification process for the Get Healthy Program but it did not address all conditions that are managed by Highmark or Intracorp. The results of the HRA were, therefore, combined with an analysis of medical and pharmacy claims to produce a more accurate picture of your health status.

I don't have the chronic condition that Intracorp/Highmark tells me I have. What makes them think I have this condition?
Neither Intracorp nor Highmark actually diagnoses a condition. Both programs use the member's HRA information along with an analysis of medical and pharmacy claims to identify members who may potentially qualify to participate in one of the programs for chronic conditions. During the recent comparison of claims and HRA data, however, there were some coding errors and differences in applying the member selection algorithms between Intracorp and its subcontractor, American Healthways. These errors may have caused a limited number of people to be misidentified as potential participants. Intracorp is in the process of correcting the status for members who may have been identified in error and is working closely with the PEBTF to communicate with those who were affected.

If I really don't have this condition, what do I do to get my risk status changed?
Only Intracorp and Highmark have the details of your health condition and how you were identified; therefore, you must discuss the identified condition with either an Intracorp or Highmark health coach. Only the health coach has the information to determine why you were identified as a potential candidate in the first place. It may be that you were identified because of a procedure or a prescription that you received that is commonly associated with certain conditions. If the health coach agrees that you have been misidentified and your status has changed, you will receive a written notification of that fact and the PEBTF will be alerted to your change in risk status.

What is the process for changing my risk status? Once the health coach agrees that I should not be in the "chronic" category, how is that change communicated so that I will know what I need to do to continue the waiver?

Intracorp or Highmark will send a file to the PEBTF regarding your correct stratification. The PEBTF will, in turn, send a file to Gordian to notify them of your risk status. You will receive a new participation letter that will tell you what your new status is and what you must do to continue your waiver.

I still don't think I have this condition but the health coach says that my claims show that I do. What should I do now?
If the health coach has determined that your claims support the condition for which you have identified, then you must engage with that health coach in order to qualify for a waiver. Remember that the health coach is reviewing your medical and pharmacy claims. If the health coach believes that the medical and pharmacy claims clearly indicate that you are being treated for this condition, the health coach will advise you of that fact and ask you to participate in management for that condition. If you believe that the claims are incorrect, you may ask the health coach to identify what services they believe indicate that you have this condition. If, after receiving this information from the health coach, you still believe that the information is incorrect, you should contact your doctor for further clarification. You may be asked to provide documentation of the fact that you do not have the condition or you may be permitted to file an appeal depending on the outcome of your contact with your doctor. The PEBTF Benefit Services Department will assist you with this process.

My health risk assessment said that I was "healthy." When I got my participation letter from Get Healthy, it said I was "at risk." I have never submitted any claims, so how did I end up in this category?
The "at risk" category was derived from a combination of factors that are listed on the HRA and not through claims information. Highmark and Intracorp made this determination by reviewing the information on the HRA. Factors such as family history and BMI (Body Mass Index) were assessed to determine if you were "at risk" or "healthy." If you believe that your "at risk" category is incorrect, contact the PEBTF. The Benefit Services Department representative will take your name, identification number and telephone number and forward this information to the appropriate individual at Highmark or Intracorp. That individual will then contact you directly to review the results of your HRA and determine whether, in fact, your health status should be changed.

When I called Intracorp to tell them that I didn't think I had this condition, they told me to contact my HR office. They said my HR office should tell the PEBTF that I should be in another risk category. Is that correct?
Absolutely not. Your HR office should not be involved in your health status and does not have any of your specific health information. The PEBTF has met with Intracorp regarding this issue and has been assured that procedures have been put in place to prevent members from being referred to their HR offices in the future. If you should have this experience, please the PEBTF for assistance and notify them that you were given this incorrect information.

Last year I got a letter from Intracorp asking me to participate in a diabetes program. I told them I did not have diabetes and they said they would remove me from their mailing file. This year, my HRA said I am "healthy" but I was notified that I am "chronic" and received another letter from Intracorp telling me I have diabetes. How did this happen?
In the disease management program that has been in effect since early 2003, members could "opt out" of the program and receive no further mailings. Because participation in the appropriate program is now tied to a waiver of your health care contribution, all "opt outs" were removed from the system and given another opportunity to participate. If you believe that you were misidentified for a condition, you should contact the health coach so that they have your status changed and place you into the appropriate program.

I got a letter that says I am "chronic" but it doesn't say what I am "chronic" for. Why can't it be more specific?
The conditions that are managed vary among the vendors (Highmark, Intracorp and Gordion) and it would be very difficult for Get Healthy to coordinate all of the letters that would need to be sent to each individual. The purpose of the letter you received was to let you know that your waiver would be effective and what you would need to do to participate. The numbers to the appropriate vendors were provided for use if you had any questions. Remember that the PEBTF Benefit Services Department is available and willing to assist members with questions.

Isn't it a violation of confidentiality and the privacy laws to give our health information to vendors like Highmark, Intracorp and Gordian?
Under the Health Insurance Portability and Accountability Act (HIPAA), your health plan is allowed by law to provide its business associates, such as Highmark, Intracorp and Gordian, with claims information for the purposes of "health care operations."

"Health care operations" includes delivering population-based activities that are related to improving health, such as disease management and wellness program activities. The PEBTF follows a strict disclosure policy in providing information to these vendors that restricts information to the absolute minimum necessary to deliver services. Each of the vendors uses policies, procedures and technology to ensure that your personal health information is protected for confidentiality in compliance with applicable laws. You may contact the PEBTF for a copy of the Notice of Privacy Practices or if you have further concerns regarding the privacy of your information.