Physician Checklist – Either done by your PCP or the Health Coach

1. The employee and covered spouse/domestic partner will have 60 days from the date they become covered under the medical plan and annually thereafter to submit the completed physician checklist to the Auburn-Lewiston YMCA (TCMHS Wellness Program Vendor) in order to receive the premium discount. If the checklist is not received by the deadline, the premium discount will be discontinued and the participant will be required to pay back the difference in premium back to the effective date of coverage. Previous tests meeting the checklist requirements dated within the prior six month period will also qualify upon submission.
2. List of the tests required for the checklist include:

• Blood Preasure
• Total Cholesterol
• HDL Cholesterol
• Body Mass Index
• Smoker/Non-smoker

The employee and/or his or her spouse/domestic partner will be required to participate in other wellness activities if results fall into a high risk category.

3. The actual test results must be included with the checklist and sent to the TCMHS Wellness Program Vendor in order to continue to receive the premium discount(s). All information received on the Physician’s Checklist is strictly confidential. No one at Tri-County Mental Health Services will have access to the information detail. Tri-County Mental Health Services will be notified that the checklist has been completed.

4. If the results of the Physician’s Checklist reflect two or more high risk factors, a BMI of 29 or over, or the use of tobacco products the employee is mandated to participate in wellness activities in order to continue receiving the premium discount (i.e., Weight Watchers, Nutritional Counseling, Smoking Cessation Program, or additional visit(s) with the Health Coach).

Weight Watchers Enrollment & Billing

Employees and their covered dependents may participate in a Weight Watchers Program and receive 100% reimbursement up to the calendar year maximum.

1. Weight Watchers programs have a calendar year maximum of $750.
2. Prior to participating in a weight watchers program, the employee and/or spouse/domestic partner must obtain a note from his or her physician stating that participation in this benefit is medically necessary. The note must be received in Human Resources before the first week of participation to be eligible for the reimbursement. If an employee and/or spouse/domestic partner’s physician’s checklist results require participation in a weight management program, that individual must participate in order for the employee to receive the premium discount. The employee will have to show proof of enrollment within 30 days of receiving notification that participation in the program is required.
3. Off-site weight watchers programs: An employee participating in the weight watchers program at an off-site location must attend three or more sessions per month for a minimum of three months and submit receipts for each meeting attended attached to a completed TCMHS Wellness Claim form to the Human Resources Department. If an employee does not meet the required attendance, he or she will not be eligible to receive this benefit again until the next plan year and be required to reimburse the agency the cost of the entire session. The employee may participate before the next plan year at his or her own cost. Human Resources will submit the receipts to Health Plans, Inc. for employee reimbursement.
4. On-site weight watchers programs: An employee participating in the weight watchers program at an on-site location must attend at least 80% of the meetings offered during the session in order to receive this benefit. Ex. 10 meeting session, would need to attend at least 8 meetings. Employees will be required to sign an attendance sheet and participate for the duration of the session to be credited for that session. If an employee does not meet the required attendance, he or she will not be eligible to receive this benefit again until the next plan year and will be required to reimburse the agency the cost of the entire session. The employee may participate before the next plan year at his or her own cost.
   
   Note: Employees not covered under our agency Health Insurance Benefit Plan may participate in on-site weight watchers programs at his or her own cost.

Nutritional Counseling

1. Employees and their covered dependents may obtain the services of a nutritional counselor and receive 100% reimbursement.
2. Prior to obtaining services from a Nutritional Counselor, the employee and/or spouse/domestic partner must obtain a note from his or her physician stating that participation in this benefit is medically necessary. The note must be received in Human Resources before the first nutritional counseling appointment to be eligible for the reimbursement. Submit receipts for each counseling session attached to a completed TCMHS Wellness Claim form to the Human Resources Department for reimbursement. If an employee and/or spouse/domestic partner’s physician’s checklist results require participation in Nutritional Counseling, that individual must participate in order for the employee to receive the premium discount. The employee will have to show proof of enrollment within 30 days of receiving notification that participation in the program is required
3. Only individuals covered under our agency Health Insurance Benefit Plan are eligible for this benefit.

Smoking Cessation

1. Employees and their covered dependents are entitled to receive 100% reimbursement for participation in smoking cessation programs.
2. Smoking cessation programs must be approved by the American Lung Association in order to qualify for reimbursement. In addition, employees and covered dependents will be reimbursed for items such as patches, gum, etc.
3. Eligible employees and dependents must certify at the time he or she elects medical coverage and, if necessary, annually thereafter that he or she will participate in a smoking cessation program. Employees and covered dependents may participate in two smoking cessation programs per calendar year. One session between January 1st and June 30th and, if necessary, another between July 1st and December 31st. Proof must be provided that the employee and/or his or her covered dependent successfully completed the program. Failure to do so will result in the employee being required to repay the difference between the smoker and non-smoker rates retroactive to the beginning of the certification period. The employee will then pay the non-discounted rate.
4. All incurred expenses, including receipts attached to a completed TCMHS Wellness Claim Form, must be submitted to the Human Resources Department for employee reimbursement

Gym Membership Reimbursement

1. All Employees may be reimbursed up to a maximum of $20 per month towards a gym membership or exercise classes taken with a certified instructor (i.e., Zumba, aerobics, yoga, etc.). If the gym membership/exercise charge is less than $20 per month, reimbursement will be the lesser amount.
2. Those attending a gym must attend 8 times per month in order to be eligible for the $20 reimbursement. At the end of each month, the employee must submit verification of attendance and a receipt of membership payment attached to a TCMHS Wellness Claim Form to Human Resources for reimbursement. Individuals who have joined for a six or twelve month membership will forward the membership contract and the membership reimbursement will be prorated each month upon receipt of the verification of attendance requirement. Those attending exercise classes taken with a certified instructor are to contact the Human Resources Department to discuss program details.
3. Reimbursement will be processed through payroll at the next payroll cycle after the Human Resources Department receives the required documentation. Note: This is a taxable reimbursement.
4. Reimbursement will be considered for any month when the proper documentation is presented.
   
   Please Note: If it is difficult due to a health factor for you to meet the requirements under the Wellness Program, or if it is medically inadvisable for you to attempt to meet the requirements of the Wellness Program, we will make available reasonable alternative standards for you to receive these discounts.