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Inpatient Hospital Deductible Reimbursement Program
(PacifiCare Deductible/Full Network Plan Participants Only)
If you participate in the PacifiCare Deductible/Full Network plan as of January 1, 2007, you can earn back all or a portion of your annual $1,500 inpatient hospital deductible by participating in one or more health and wellness programs. Depending on which program(s) you participate in and the length of your involvement, you’ll earn credits that are used to reimburse your payment toward the inpatient hospital deductible if you become hospitalized.
Read on for more details and instructions on requesting a reimbursement.
Description of Health and Wellness Programs and Associated Credits
This voluntary VEBA program is for adult members only. Deductibles paid for enrolled dependent children under age 18 (substantiated by submitting proof of payment) will be reimbursed regardless of participation in the following programs.
You can earn reimbursement from VEBA by attesting to your participation in one or more of the following programs and submitting proof of payment of your inpatient hospital deductible within 365 days of your discharge date. You will be reimbursed up to the amount of credits you’ve earned at the time of your reimbursement request, not to exceed $1,500 in any continuous 12-month period. Please note that you will not receive reimbursement if you are not hospitalized, even if you earn credits by participating in the programs listed below.
Eligible Health and Wellness Programs
| Program
|
Description
|
Credits
|
Request
Reimbursement...
|
Value Network Primary Care Physician (PCP) selection
|
Use a Value Network (non-Scripps Clinic) PCP for a continuous 12-month period
|
$1000
|
After you complete a continuous 12-month period with the same non-Scripps Clinic PCP
|
Best Doctors®
program participation
|
Qualify to have your health care case confidentially reviewed by leading medical experts at Best Doctors
|
$500
|
After you sign and submit a service request form to Best Doctors (participation will not be disclosed to PacifiCare or your employer)
|
| VEBA Weight Loss Challenge participation
|
Qualify and be selected to participate in the VEBA Weight Loss Challenge
|
$300 total
 |
$100 (first six months |
|
$200 second
six months |
|
After first six months you can submit a request; after second six months you can submit an additional request; or you can submit your request at end of 12-month period
|
| Health Risk Assessment (HRA) completion
|
Complete a PacifiCare HRA online at
www.pacificare.com
|
$300
|
After you fully complete and submit the online HRA (only one completion per 12-month period will be reimbursed)
|
| Disease management program participation
|
Participate in a PacifiCare disease management program for six to 12 months.
Case-based programs
|
Coronary artery disease |
|
Congestive heart failure |
|
Chronic obstructive pulmonary disease |
|
End stage renal disease |
| Taking Charge®,SM
programs |
|
Asthma |
|
Diabetes |
|
Coronary artery disease |
|
Congestive heart failure |
|
Depression |
|
$500 total
|
$200
(first six months) |
|
$300 (second
six months) |
|
After first six months you can submit a request; after second six months you can submit an additional request; or you can submit your request at end of 12-month period
|
| PacifiCare VirtualHealthClub participation
|
Participate in online VirtualHealthClub at
www.pacificare.com
(e.g., create and monitor a fitness or nutrition plan, dialogue with a coach, review recipes)
|
|
$200 (first 10 weeks in a 12-month period) |
|
$20 (each additional week in a 12-month period) |
|
After first 10 weeks you can submit a request; after each additional week you can submit a request (however, it’s recommended that you batch multiple additional weeks together)
|
Medical
group/hospital utilization
|
Use a particular medical group or hospital when you need hospital services, depending on the group to which your PCP belongs
| If your PCP is
with: |
|
Sharp Rees-Stealy — use Sharp Memorial Hospital |
|
Sharp Mission Park medical groups —
use Sharp Memorial Hospital |
|
Scripps Clinic —
use Scripps Green Hospital |
|
$500
|
After hospital services are received (must submit proof of admission if hospital name is not printed on the proof of payment)
|
| Healthy Pregnancy program participation
|
Enroll in the PacifiCare Healthy Pregnancy Program (must be pregnant)
|
$500
|
After you enroll with PacifiCare either online or by phone
|
| Another qualified, formalized health-improvement program
|
If you participate in a formalized
health-improvement program for at least six months, your participation may qualify to earn a credit. You will be required to submit a program description and
proof of your participation. The VEBA Advocacy Programs office will determine whether or not the program
you participate in qualifies toward earning a credit.
|
$500
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After six months participation (must submit program description and proof of participation)
|
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Important Program Rules
Here are some important rules about the reimbursement of the PacifiCare Deductible/Full Network plan annual inpatient hospital deductible.
- You must participate in the PacifiCare Deductible/Full Network plan (and have been a member as of January 1, 2007) in order to be reimbursed for your inpatient hospital deductible.
- A dependent child added after January 1, 2007, and subsequently hospitalized, is eligible for reimbursement of the inpatient hospital deductible.
- You will be reimbursed only if you become hospitalized and pay a portion or all of your inpatient hospital deductible. If you are not hospitalized, you will not receive a payment of any credits you’ve earned by participating in the health and wellness programs.
- Participants under age 18 who become hospitalized will be reimbursed for their inpatient hospital deductible regardless of whether they participate in the designated health and wellness programs. You or the participant must submit proof of payment of the participant’s inpatient hospital deductible within 365 days of the hospital discharge date.
- You earn credits and request reimbursement based on a “rolling” (continuous) 12-month period. A continuous 12-month period begins on the date you are discharged from the hospital and ends 364 days later. Your $1,500 inpatient hospital deductible is charged on a calendar year basis. (You pay the inpatient hospital deductible only once per calendar year, regardless of the number of times you are hospitalized.)
- You will be reimbursed up to the amount you have paid toward your deductible or the amount of credits earned, whichever is less. For example, if you’ve paid $600 toward your deductible but only have $500 in credits, you will be reimbursed $500.
- The maximum amount you will be reimbursed in any continuous 12-month period is $1,500.
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How to Get Reimbursed
If you (or your dependent) become hospitalized and pay a portion or all of your inpatient hospital deductible, be sure to keep your proof of payment. You will need it to request reimbursement. Examples of proof of payment include:
- A receipt
- A hospital bill showing the amount you paid toward your deductible
- An explanation of benefits showing the amount you paid toward your deductible.
You may begin the reimbursement process by downloading the Inpatient Hospital Deductible Reimbursement Request
Form. Complete the form and follow the instructions on the form for submission. You should receive your reimbursement check within three to four weeks of submitting your request.
You may also contact the VEBA Advocacy Programs office with any questions or to request a reimbursement form: (619) 278-0021 phone; (619) 278-0024 fax,
info@vebaonline.com.
Please note: If you participate in the Medical Group/ Hospital Utilization feature of the program, faxing your proof of payment showing the name of the hospital to which you were admitted also counts as documentation. If your proof of payment does not show the hospital to which you were admitted, you will need to submit other documentation to verify that you were admitted to the appropriate hospital in order to receive reimbursement.
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Program Summary and Reimbursement Request Form
Below are links to a one-page summary of the reimbursement program, as well as a receipt submission form when you need to request reimbursement.
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