Frequently Asked Questions

Click on one of the links below to learn more about each topic.

About Adventist Health Plan

2019 Engaged! Premier Program

Unavailable Service Request Forms

Usual and Customary Charges

LivingWell


Adventist Health Plan

Q: How many levels does the plan offer?
A: The plan offers two levels of benefits: AH and PPO. AH level benefits are, generally, more generous than PPO level benefits. In general, out-of-network services are not covered under the plan. There are some additional exceptions, like remote clinics.

Q: Where can I receive my health care services?
A: Services provided by Adventist Health providers and services rendered at Adventist Health facilities are covered as AH level benefits. Services rendered by PPO providers and services rendered at PPO facilities are covered as PPO level of benefits. Out-of-network services are, generally, not covered under the plan.

Q: Who is a PPO provider?
A: A physician or professional provider who is in the PPO network, but who is neither a member of the Adventist Health medical staff nor a Healthcare Resources NW (HRNW) provider.

  • The Blue Shield PPO provides a network of California providers for California employees.
  • The First Choice PPO provides a network of Oregon and Washington providers for AMC - Portland employees.
  • The First Health PPO provides a network of Oregon providers for Tillamook and Oregon-based Western Health Resources & Corporate associates. First Health PPO also serves as a network of providers for California and Adventist Health Portland Associates utilizing providers in states other than California.

Q: Where can I find a list of Blue Shield, First Health or First Choice providers?
A: Navigate to http://www.ahprovider.org/ and scroll down to the hyperlinks for Blue Shield of California PPO, First Choice (PPO Level), and First Health. For Blue Shield, be sure to select the plan “Blue Shield of California PPO Network.”

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2019 Engaged! Premier Program

Q: What is the difference between the Engaged! Plan and the Engaged! Premier Program?

A: The Engaged! Plan offers a wellness program called the Engaged! Premier Program. This program is designed to encourage associates and their families to take an active role in their wellbeing. The Engaged! Premier Program offers the benefits of the Engaged! Plan that you know and love, and is provided to you at a lower monthly contribution than the standard Engaged! and Base plan options. To be eligible to participate in this program for 2019 you must complete the wellness requirements outlined in the 2018 Engaged! Premier Program by August 31, 2018. To be eligible to participate in 2020, you must complete all wellness requirements outlined in the 2019 Engaged! Premier Program by August 31, 2019.

The Engaged! Plan is also available without Premier Program participation. This plan has all the same benefits of the Engaged! Premier Program, but without you having to complete the wellness requirements. You will, however, be required to pay a higher monthly contribution to participate in the Engaged! Plan without Premier Program participation.

    Q: What do I (and my spouse/Registered Domestic Partner (RDP), if applicable) need to do in order to participate in the Engaged! Premier Program for 2019?

    A: If you and your spouse/RDP are currently enrolled in the 2018 Engaged! Premier Program and have completed all the wellness requirements, you will continue to be enrolled in the 2019 Engaged! Premier Program. There is no need to re-enroll.

    If you and your spouse/RDP are currently enrolled in the 2018 Base Plan or Engaged! Plan without Premier Program participation, and not currently enrolled in the 2018 Engaged! Premier Program, but would like to participate in the 2019 Engaged! Premier Program, you will need to re-enroll during the Open Enrollment period from November 5-21, 2018. Enrollment/change forms are available online at claimscentral.ah.org

    If you want to continue in the Engaged! Premier Program in 2020, you must complete the wellness requirements in 2019. See section below, “What is required for 2020 Engaged! Premier Program eligibility?”

    Q: What is required for 2020 Engaged! Premier Program eligibility?

    A: You and your covered spouse or RDP, if applicable, must meet the following requirements in 2019 to be eligible to enroll in the 2020 Engaged! Premier Program:

    1. Complete a biometric screening between May 15 and August 31, 2019;
    2. Complete an online wellness assessment between May 15 and August 31, 2019;
    3. Participate in care management and/or health coaching if identified by the plan administrator as someone who would benefit from care management; and
    4. Earn 100 LivingWell points by August 31, 2019. This requirement applies to continuing Engaged! Premier Program members. Points are prorated for new members who join the plan between January 1, 2018 and August 31, 2019.

    Q: What if I fail to do one or all of these prequalification steps for the 2020 plan year?

    A: If you do not complete one or all of the above steps in 2019 for the 2020 enrollment, you will not be eligible to enroll in the Engaged! Premier Program for 2020, however your spouse (if he/she has met the requirements) and your covered dependents will be eligible to enroll in the Engaged! Premier Program, while you may enroll in the Engaged! Plan without Premier. Alternatively, you and your enrolled dependents will be eligible for the Base Plan.

    If at any point in time you (or your covered spouse/RDP) do not complete participation in care management and/or health coaching, you and all covered dependents will be moved to the Base Plan the following year. Alternatively, you may elect to enroll yourself, any covered children and your spouse/RDP (if eligible) in the Engaged! Plan without Premier Program participation during the annual Open Enrollment period. See the scenarios below.

    Scenario 1:

    • Associates earns 100 points
    • Spouse does not earn 100 points

    You and all of your covered dependents will be moved to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll yourself and any covered children in the Engaged! Premier Program, and your spouse in the Engaged! Plan without Premier Program participation.

    Scenario 2:

    • Associates does not earn 100 points
    • Spouse earns 100 points (or is not covered by plan)

    You and all of your covered dependents will be moved from the Engaged! Premier Program to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll in the Engaged! Plan without Premier Program participation, and your spouse and any covered children in the Engaged! Premier Program.

    Scenario 3:

    • Employee does not earn 100 points
    • Spouse does not earn 100 points

    You and all of your covered dependents will be moved from the Engaged! Premier Program to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll yourself and all your covered dependents in the Engaged! Plan without Premier Program participation.

    Q: Will my spouse or I be moved to the Base Plan or be ineligible for the Engaged! Premier Program if our cholesterol, blood pressure, blood sugar or weight is too high?

    A: No. You will not be moved to the Base Plan or be ineligible to enroll in the Engaged! Premier Program based on your individual biometric numbers. No eligible employee and spouse/RDP will be denied enrollment in our health plan due to pre-existing or current health issues, or because his/her biometric numbers fall within the unhealthy range.

    Q: If my spouse/RDP or I have biometric screening results outside of healthy ranges will it affect my insurance premiums or contributions?

    A: No. Your insurance contributions will not be affected by your biometric numbers.

    Q: What if my or my spouse’s/RDP’s biometric screening results fell outside of healthy ranges in 2018 and don’t improve in 2019? Will I or my spouse be declined coverage? Will my premiums or contributions increase?

    A: No. While we hope that the biometric screening results raise your awareness and prompt you to take action to improve your health, you will not be denied coverage next year, nor will your individual contribution be impacted by your or your spouse’s biometric numbers.

    Q: What is care management and health coaching?
    A: Care management and health coaching are additional, confidential resources to support individuals identified with or being at high risk for serious illness, or for those struggling to manage their personal health goals. For example, an individual identified with a serious illness may have multiple conditions, may take multiple prescriptions and/or may see multiple physicians. An individual needing assistance with developing and managing personal health goals may be identified based on the results from the most recent biometric screening.

    Q: What happens if I am selected for confidential care management and health coaching?
    A: If you are selected for care management or health coaching, you will be contacted by one of the health plan care managers or health coaches. If appropriate, you will be asked to participate. A member of the care management team will explain the process and answer your questions. If you are enrolled in the Engaged! Premier Program, you agreed to participate in care management, however health coaching is voluntary. Participation includes actively participating in setting personal goals and discussing progress toward those goals with your assigned care manager/health coach. This is an opportunity for you to collaborate with a professional about your health.

    Q: What if I have high cholesterol, high blood pressure, am overweight or smoke? Will I be contacted for care management or health coaching?
    A: You may or may not. Members identified for care management or health coaching are selected based on a number of factors. If you struggle with one or more of these health risks, we encourage you to seek care from your primary care physician. If you already are, we thank you for taking care of your health.

    Q: Will adult dependent children enrolled in the plan be required to complete the Engaged! Premier Program requirements?
    A: No. The requirements only apply to employees and enrolling spouses.

    Q: What if I need to complete a preventive screening such as a mammogram, colonoscopy or cervical cancer screening because of my age? Will I be required to do this in order to be enrolled in the Engaged! Premier Program?

    A: No. While we hope that you and your provider design a preventative care plan that is right for you, and includes these important screenings, you will not be required to complete these screenings to remain enrolled in the Engaged! Premier Program.

    Q: What is a biometric screening and why should I know my numbers?

    A: A biometric screening is designed to raise awareness of your health factors—to know your numbers. A screening is not a diagnostic process and does not replace tests that your personal care provider would perform or the advice and treatment he/she would provide.

    A biometric screening is a combination of measurements and readings about certain health factors that may be helpful in identifying potential risk factors for chronic diseases or conditions, like heart disease, hypertension, or diabetes. Most of the risk factors identified through our onsite screenings do not have associated symptoms. A biometric screening can help you proactively identify possible risk factors that may lead to chronic illness. Or, you could simply confirm your health status and gain peace of mind. All information is kept confidential and complies with the requirements of HIPAA (Health Insurance Portability and Privacy Act of 1996).

    Q: How is a finger stick performed?
    A: A small puncture is made in the finger and approximately four drops of blood are withdrawn.

    Q: What will be measured at the 2019 biometric screening?
    A: You will receive the following information at your biometric screening: Total Cholesterol, HDL (good cholesterol), blood pressure, and blood glucose (sugar). LDL (bad cholesterol) and triglycerides (fats in your blood) will be measured if you are fasting. Height, weight, body mass index (BMI) and body composition also will be measured. Eligible associates and spouses will also have the option of doing a hemoglobin A1c test to indicate blood sugar levels during the previous three months.

      Q: When and how will I get the results of my screening?
      A: Your results will be provided to you at the time of the screening. They also will be uploaded to your confidential, password-protected health profile available through the LivingWell website.

      Q: Can I talk to someone about my results?
      A: You are encouraged to discuss your results with your doctor or contact an Employee Health Plan health coach.

      Q: Does the biometric screening cost me anything?
      A: No. Adventist Health covers the cost and your participation is free. This is part of our commitment and investment in your health.

      Q: Does this biometric screening replace an annual physical with my doctor?
      A: No. Biometric screenings do not replace a complete preventive annual exam with a physician. It is meant to alert you to potential risk factors. We encourage you to follow-up with your personal physician or other health care professional for further care.

      Q: How will I know when it is time to complete a biometric screening and wellness assessment?
      A: Biometric screenings will be scheduled at our Adventist Health locations in 2019 between May 15 and August 31, prior to open enrollment for 2020 coverage. You may complete your wellness assessment online at LivingWell.ah.org during this same timeframe, May 15 - August 31. Your employer will notify you when it is time to schedule your screening and complete your assessment.

      Q: Will my employer know my biometric screening and wellness assessment information?
      A: No. Adventist Health uses a third-party vendor for the biometric screenings to ensure your privacy is protected. Your employer will not receive any private health information about you or your spouse/RDP, ever.

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      Unavailable Service Request Forms

      Q: What if my provider says I need a procedure that isn’t available from an in-network provider or at an in-network facility?
      A: You must complete and submit an Unavailable Service Request Form (USRF). This form is needed for a medically necessary, covered service:

      • At any non-Adventist Health facility, and/or
      • With any non-Adventist Health or non-PPO provider

      Q: Do I need pre-approval before I get care from out-of-network providers and facilities?
      A: Yes, except for emergency and urgent care services.

      Q: What happens if I don’t get pre-approval?
      A: With the exceptions above, the service will not be covered.

      Q: How do I know if a service or physician is available in-network?
      A: Visit ahprovider.org to find a provider near you. If you believe medical services are not available from an in-network provider or facility, you or your provider should call Customer Service at (800) 441-2524.

      Q: How is a determination made?
      A: The health plan team verifies that the covered service is not available in-network.

      Q: Why can’t I get treatment wherever I want?
      A: You can. However, unless the covered service is with an Adventist Health or PPO provider and is provided in an Adventist Health facility, you will not be reimbursed (see emergency/urgent care exception).

      Q: How do I submit an unavailable service request?
      A: Follow these three steps:

      • Visit Connect, the employee intranet portal, open the Health Plan Homepage, click on the Health Plan Forms folder and click on the USRF link. Type in all required information. Save, print and fax, or save and eFax the completed form to (916) 781-0853.
      • Once you’ve provided all the information needed to process the request, allow up to seven business days for review. You must get approval before the service is provided with the exception of urgent or emergency care.
      • A team member from Adventist Health’s employee health plan will contact you by phone and/or send a letter to you and your provider once a determination is made.

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      Usual and Customary Charges

      Q: What does “usual and customary charge” mean?
      A: This is the amount providers in a geographic area usually charge for the same or similar medical service, supply or medicine.

      Q: How does it affect me?
      A: In most cases, it won’t, as only three percent of all medical claims come from providers outside of Adventist Health’s network of preferred providers. However, with dental and vision, because you may see any provider you choose, it is more likely you could be affected. If a provider charges above the usual and customary amount for a service covered under the plan, you must pay the difference.

      Most Adventist Health facilities* participate in the DenteMax dental PPO. Choosing a DenteMax PPO provider may result in your dental care costs being significantly less. DenteMax participating providers have agreed to provide reduced-rate services to you and your covered dependents. You can find a list of DenteMax participating providers by going to www.dentemax.com or by calling customer service at (800) 441-2524.

      Q: How is the usual and customary charge determined?
      A: The health plan contracts with a vendor that determines the usual and customary charge by surveying providers in a specific geographic area. The employee health plan bases the usual and customary charge using the 85th percentile of all charges for the same service or supply in that area.

      Q: How can I find out if my provider charges about the usual and customary amount?
      A: You can call customer service at (800) 441-2524, identify your facility and ask to speak to a claims examiner. You will need to provide the examiner with the zip code of the provider and the five-digit CPT code (for medical) or ADA code (for dental), which describes the procedure or service.

      *Facilities without DenteMax include Adventist Health Howard Memorial, Adventist Health St. Helena and Tillamook Regional Medical Center.

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      LivingWell

      Q: Why do I have to complete LivingWell points if I am healthy?
      A: LivingWell is a lifestyle. It’s remaining aware of and being responsible for your health on a continual basis, beyond open enrollment or your annual physical exam. Maintaining your good health requires healthy choices and actions every day.

      Q: How do I earn points?
      A: Visit the LivingWell.ah.org website for ways to earn points and to learn about site-specific fitness events, workshops and other activities.

      Q: How will my points be tracked?
      A: Fifteen points will automatically be uploaded to your LivingWell account after your onsite summer biometric screening, and another 10 after you complete your summer wellness assessment. You will need to log your points for exercise, good nutrition, exams/vaccinations, classes, etc., on the LivingWell website (LivingWell.ah.org).

      Q: What If I don’t earn 100 points by August 31?
      A: Scenario 1:

      • Employee earns 100 points
      • Spouse does not earn 100 points

      You and all of your covered dependents will be moved to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll yourself and any covered children in the Engaged! Premier Program, and your spouse in the Engaged! Plan without Premier Program participation.

      Scenario 2:

      • Employee does not earn 100 points
      • Spouse earns 100 points (or is not covered by plan)

      You and all of your covered dependents will be moved from the Engaged! Premier Program to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll in the Engaged! Plan without Premier Program participation, and your spouse and any covered children in the Engaged! Premier Program.

      Scenario 3:

      • Employee does not earn 100 points
      • Spouse does not earn 100 points

      You and all of your covered dependents will be moved from the Engaged! Premier Program to the Base Plan. Alternatively, you may, within 31 days of the determination, elect to enroll yourself and all your covered dependents in the Engaged! Plan without Premier Program participation.

      Q: What if I am physically unable to participate in an activity?
      A: It’s important to consult with your physician for advice on whether a physical activity is appropriate for you. There are other ways to earn points through screenings, vaccinations, classes, workshops and volunteering. If you need accommodations or reasonable alternatives for earning points, please contact Human Resources.