Hap Member Qualification Form – Fill Out and Use This PDF

Dear Valued Member:

We are happy you are taking part in Aspire, a Health Engagement program. This program rewards healthy lifestyle choices by saving you money on out-of-pocket costs.

Save money—choose the Aspire Enhanced Plan!

The Enhanced plan can help save you money on your out-of-pocket costs, but requires a commitment on your part. Both you and your covered spouse will have to complete these three easy steps by

1.Have your personal care physician (PCP) complete the Member Qualiication Form located in the middle of this booklet.

2.Demonstrate your commitment to good health with a score of at least 80 on your Member Qualiication Form. We can help you meet your goals!

3.Log in at hap.org and complete the free SUCCEED® Health Risk Assessment.

Standard Plan

The Standard plan provides the same quality of care, but with higher copays and deductibles. At the end of your qualiication period, if you and/or your covered spouse have not completed the three steps to qualify for the Enhanced plan, you will automatically be placed in the Standard plan.

If you have any questions about Aspire, call Customer Service Monday through Friday, 7 a.m. to 7 p.m., and 8 a.m. to noon on Saturday at (888) 819-2540. If you are deaf, hard of hearing or speech impaired please use our TDD/TTY phone line at (800) 649-3777. Login at hap.org to check your status, view Frequently Asked Questions, download a copy of your Member Qualiication Form and more.

As always, your membership is appreciated, and we look forward to serving as your health plan for many years to come!

Sincerely,

Richard D. Chaney

Vice President, Customer Service

Aspire to be Healthier

We believe a health plan should look out for your well-being. That’s why we created Aspire, a Health Engagement program designed to reward you as you participate in making healthier lifestyle choices.

A step-by-step guide to choosing the Enhanced plan

If you choose to stay in the Enhanced plan, you and your covered spouse need to complete the following steps by the end of the qualiication period.*

Step 1. Complete and submit your Member Qualiication Form.

Schedule an appointment with your personal care physician (PCP). If you don’t have a PCP, you can choose one by logging in at hap.org and selecting “Find a Doctor/Facility.”

Be sure the form is completed in full and submitted before the end of the qualiication period. Either you or your doctor can submit the form, but please keep a copy for your records. If your doctor submits the form for you, you are responsible for ensuring that we receive the form on time. You can view your status anytime by logging in at hap.org.

Step 2. Score at least 80 points on your Member Qualiication Form.

Points are assigned based upon meeting speciic wellness targets or by participating in health improvement programs. To qualify for the Enhanced plan, you will need to meet the wellness targets listed on the Member Qualiication Form to earn 80 points. If you do not or cannot meet the wellness targets, you still may be able to meet the program requirements by working with your doctor.

If you’re not willing to commit to lifestyle changes or work with your doctor to meet the 80-point program requirements, you will be moved to the Standard plan with higher out-of-pocket costs.

Step 3. Complete your Health Risk Assessment.

To help you understand your health risks, complete the free conidential online SUCCEED® Health Risk Assessment. It takes about 20 minutes to complete.

To ind the assessment, log in at hap.org using your health plan ID number and password, then select the Health Risk Assessment link from the Quick Links section. If you have not registered yet, select Register Now. After registering you will be redirected to the hap.org homepage to log in.

The personal health information you enter online in the assessment will not be shared with any other party without your speciic consent, as required by law.

At the end of your qualiication period, if you and/or your covered spouse have not completed the three steps to qualify for the Enhanced plan, you will automatically be placed in the Standard plan with higher out-of-pocket costs.

Example of how to save with the Enhanced plan.

Helen’s employer ofers the Health Engagement plan. The plan provides Helen with a $1,000 deductible and higher copays if she stays in the Standard plan; but Helen will have no deductible in the Enhanced plan.* Helen is in pretty good health. Recently though, she hurt her knee. Helen’s PCP referred her to a specialist. The specialist recommends an outpatient procedure to help Helen recover. Helen’s out-of-pocket costs will be much lower in the Enhanced plan than the Standard plan, as shown by the chart below:

	Enhanced Plan	Standard Plan
PCP Visit	$15	$30
Specialist Visit	$30	$45
Outpatient Copay	$100	$100
Deductible	$0	$1,000
Total out-of-pocket costs:	$145*	$1,175*

*Costs vary based on your speciic plan. This example shows a typical Health Engagement beneit plan. Please check with your beneit administrator for a complete summary and cost-sharing breakdown for your plan.

We want to help you meet your goals.

Take advantage of the programs and services geared to help improve your health — and your out-of-pocket costs.

•To stop tobacco/nicotine use, several treatment plans are available to help you quit:

-Smoking (tobacco/nicotine) cessation counseling services provided by your PCP

-Smoking Intervention Program (SIP) or Freedom From Smoking Program (FFS)

-Prescription and over-the-counter smoking (tobacco/nicotine) cessation drugs or products, such as nicotine patches, gum, nasal spray or inhaler*

-Electronic counseling services with the HealthMedia® BREATHETM program

* You may be asked to send in your receipts for over-the-counter products that helped with your tobacco cessation treatment. If you are asked for your receipts for any of the previous options, please send them to: HAP, Attn: Correspondence Department, 2850 W. Grand Blvd., Detroit, MI 48202. Or fax your receipts to (313) 664-8400.

Don’t forget to include your name and health plan ID number.

•HAP’s Restore CareTrack®– an award-winning disease management program that includes support from a nurse health coach and other resources to help with chronic conditions.

•HAP’s Weight Management program ofers nutritional counseling as well as doctor-supervised and prescription-assisted weight loss programs. You can also get deep discounts on Weight Watchers® memberships.

To learn more about our many programs and services, log in at hap.org.

Notice of Reasonable Alternative

We are committed to helping you achieve your best health. Rewards for taking part in a wellness program are available to all employees. If you are not able to meet a standard for a reward under any of our wellness programs, you might qualify for an opportunity to earn the same reward by diferent means. We will also work with your doctor, if you wish, to ind a wellness program option with the same reward that is right for you.