NY Essential Gym Flyer

Get Active. Get Healthy. New York Essential
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Plans Will Cover Your Gym Fees!
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Your gym reimbursement benefit can save you money.1 It’s simple. Visit a qualifying gym at least 50 times in six
months. Then we pay your membership fees.2
This benefit is available to New York Essential Plans members who have been with the plan for six consecutive months.
What types of health
clubs are eligible?
Your eligible health club must promote
cardiovascular wellness and offer at least two
pieces of equipment or activities from the
following list:
•Treadmill •Ellipticalcross-trainer
•Stationarybicycle
•Stairclimber
•Rowingmachine
•Tennis/racquetballcourts
•Pool •Groupfitnessclasses
Some types of health clubs are not eligible. You will not be reimbursed fees you pay to clubs that are
not eligible. Ineligible clubs include:
• Country clubs • Sports teams
• Weight loss clinics
• Martial arts centers
• Other similar facilities
Also, fees for personal training, coaching, equipment and clothing are not eligible.
1.� Benefit dollar amounts vary by plan. Contact Customer Service to confirm your policy’s benefit.
2.�If your six-month membership is more than your benefit amount, you will only be reimbursed up to the benefit amount allowed. If your membership fee is less than your benefit amount, you will be reimbursed the lesser amount.
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NY031490_HIX_FRM_ENG Internal Approved 09172015
©WellCare 2015 NY_09_15
NY6HIXFRM70472E_0915
Gym Reimbursement Form
WellCare Health Plans-GYMDMR P.O. Box 31396 Tampa, Florida 33631-3396
SUBSCRIBER INFORMATION (Coverage Holder):
Subscriber Name: ________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Subscriber Address: _______________________________________________________________________
(Number and Street)
(City)
(State)
(ZIP Code)
Subscriber ID: ____________________________________ Date of Birth: ___________________________
When can I claim my reimbursement?
Each reimbursement period begins on the day of your first gym visit. It ends six months after that.
We will pay you back after the six months pass. The period does not end when you complete 50
visits. The benefit does not roll over to the next year. That means it must be completed during the
benefit year.3
How do I claim my reimbursement?
1. Visit a qualified health club at least 50 times in six months.
2. Get printed documentation for each visit. (Ask your health club for this.) Please do not
submit originals. 3. Get a copy of your current health club bill. It should show the cost of your membership and
proof of payment.
4. Complete the Gym Reimbursement Form found on the next page.
5. Mail us: (1) proof of visits, (2) a copy of your health club bill, and (3) the completed Gym Reimbursement Form. Please allow 30 days for payment.
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Please call Customer Service if you have questions about this benefit. You can reach us at
Member Name: __________________________________________________________________________
(Last Name)
(First Name)
(Middle Initial)
Member ID: ____________________________________ Date of Birth: ____________________________
Claimant is (Check One):
o Subscriber (coverage holder)
o Spouse (of coverage holder)
o Covered Dependent
FACILITY INFORMATION:
Six-month period requested: Start date: _______________________ End date: ______________________
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Name of Facility: _________________________________________________________________________
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Facility Address: __________________________________________________________________________
(Number and Street)
(City)
(State)
(ZIP Code)
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Facility Employee’s Signature: _______________________________________________________________
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Facility employee’s signature above affirms that the facility promotes cardiovascular wellness for members. False statements will result in the denial of reimbursement. By signing below, I am agreeing that all of the information listed above is full, complete and true to the best of my knowledge. Subscriber/Member’s Signature: _____________________________________ Date: ___________________
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Mail completed form (including proof of visits and a copy of the facility bill):
Wellcare Heath Plans – GYMDMR
P.O. Box 31396
TAMPA, FL 33631-3396
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70472
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If you speak a different language or need something in Braille or audio, don’t worry. We can provide translations and alternate
1-855-582-6172,
Monday–Friday.
TTY users
may call
1-855-582-6171.
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If
you speak
different
language
or us
need
something
or audio,
don’t1-855-582-6171).
worry. We can provide translations and alternate
formats
at noaa cost
to you.
Just give
a call
toll-free in
at Braille
1-855-582-6172
(TTY
If
you
speak
different
language
or
need
something
in
Braille
or
audio,
don’t1-855-582-6171).
worry. We can provide translations and alternate
formats
at
no
cost
to
you.
Just
give
us
a
call
toll-free
at
1-855-582-6172
(TTY
If
you speak
a cost
different
language
or us
need
something
in
Braille
or audio,(TTY
don’t1-855-582-6171).
worry. We can provide translations and alternate
formats
at
no
to
you.
Just
give
a
call
toll-free
at
1-855-582-6172
If
you speak
a cost
different
language
or us
need
something
in
Braille
or audio,(TTY
don’t1-855-582-6171).
worry. We can provide translations and alternate
formats
at
no
to
you.
Just
give
a
call
toll-free
at
1-855-582-6172
Si
usted
habla
un
idioma
diferente
o
necesita
algo
en
Braille
o
audio,
no
se
preocupe.
Nosotros podemos proporcionarle
formats
at
no cost
to you.
Just giveous
a call toll-free
at 1-855-582-6172
(TTY
1-855-582-6171).
Si
usted
habla
un
idioma
diferente
necesita
algo
en
Braille
o
audio,
no
se
preocupe.
podemos proporcionarle
traducciones
formatos
sin costoalgo
paraenusted.
llámenos
sin Nosotros
cargo al 1-855-582-6172
(TTY 1-855-582-6171).
Si
usted hablayyun
idioma alternativos
diferente o necesita
BrailleSimplemente,
o audio, no se
preocupe.
Nosotros
podemos proporcionarle
traducciones
formatos
alternativos
sin
costo
para
usted.
Simplemente,
llámenos
sin
cargo
al
1-855-582-6172
(TTY 1-855-582-6171).
Si
usted
habla
un
idioma
diferente
o
necesita
algo
en
Braille
o
audio,
no
se
preocupe.
Nosotros
podemos
proporcionarle
traducciones
yun
formatos
alternativos
sin costoalgo
paraenusted.
Simplemente,
llámenos
sin Nosotros
cargo al 1-855-582-6172
(TTY 1-855-582-6171).
Si
usted
habla
idioma
diferente
o
necesita
Braille
o
audio,
no
se
preocupe.
podemos
proporcionarle
traducciones y formatos alternativos sin costo para usted. Simplemente, llámenos sin cargo al 1-855-582-6172 (TTY 1-855-582-6171).
traducciones y formatos alternativos sin costo para usted. Simplemente, llámenos sin cargo al 1-855-582-6172 (TTY 1-855-582-6171).
MEMBER INFORMATION:
3. Members effective on or after August 1 must complete the 50 visits before the end of the year to be eligible for reimbursement. You will be
reimbursed for the months you were eligible for the benefit.
NY031490_HIX_FRM_ENG Internal Approved 09172015
©WellCare 2015 NY_09_15
NY6HIXFRM70472E_0915
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