QualityPath® Employer Plan Design
The Alliance® provides a detailed plan design for employers to use when implementing QualityPath. Check out the detailed SPD model plan language and the highlights
Mandatory Elements
For Tests (CTs, MRIs, and Colonoscopies)
- 100 percent coverage for services in the bundle. The deductible is waived for QualityPath; however, the employee still pays the deductible when using other health services. This is modified for plans with health savings accounts (HSAs) to comply with Internal Revenue Service (IRS) rules.
- Patients are encouraged to tell The Alliance when they are having a QualityPath CT or MRI by calling the Patient Experience Manager at 800.223.4139 x6607. Patients who forget still get QualityPath’s lower price. However, they may be unaware of the warranty and end up paying more if a repeat scan is required.
For Surgeries
- 100 percent coverage for pre-operative care; inpatient care; post-operative care and physical therapy/cardiac rehabilitation; and any services covered under the QualityPath warranty. The deductible is waived for QualityPath; however, the employee still pays the deductible when using other health services. This requirement is modified for plans with HSAs.
- Patients are required to call the Patient Experience Manager at 800.223.4139 x6607 to be eligible for QualityPath’s enhanced benefits. If the patient does not inform The Alliance, they and their employers do not receive QualityPath pricing.
Optional Enhancements
Eligibility & Eligible Services
For Surgeries and Tests
- Exclusive Provider Organization (EPO) plans are ineligible.
- Only people who have primary insurance that uses The Alliance network qualify for QualityPath; patients with secondary insurance do not have access to QualityPath benefits and services.
For Surgeries
- QualityPath covers only medications given during the inpatient stay; coverage for other prescriptions is based on the employer’s health plan.
- Sub-acute care provided at a facility such as a nursing home is covered only for a patient who has a bilateral knee replacement; for all other patients, this care is not covered.
- QualityPath can be extended to employees outside The Alliance service area if your third party administrator (TPA) can support it. Talk to your Account Executive to learn more.
For Surgeries and Tests
Optional enhancements can provide an incentive when a patient has already hit the out-of-pocket maximum and so does not benefit from 100 percent coverage. These enhancements may include:
- Cash incentives or bonuses.
- Reimbursement for travel expenses (mileage, parking, tolls).
- Hotels.
- Per-diem travel allowances.
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