Get Active. Get Healthy. New York Essential � Plans Will Cover Your Gym Fees! � 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. � 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. � 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: ______________________ � Name of Facility: _________________________________________________________________________ � Facility Address: __________________________________________________________________________ (Number and Street) (City) (State) (ZIP Code) � Facility Employee’s Signature: _______________________________________________________________ � 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: ___________________ � 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 � 70472 � 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. � 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 �