Plan Design for QualityPath
The Alliance provides detailed SPD model plan language for employers to use when implementing QualityPath.
Highlights of plan design language are provided below.
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 required to tell The Alliance when they are having a QualityPath colonoscopy by going to qualitypath.com/TellUs. Patients may also call The Alliance Customer Service Department at 800.223.4139. Patients who do not tell The Alliance in advance will not get QualityPath’s enhanced benefits. If the patient does not inform The Alliance, employers do not receive QualityPath pricing.
- Patients are encouraged to tell The Alliance when they are having a QualityPath CT or MRI by going to qualitypath.com/TellUs. Patients who forget or do not use the Internet 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.
- 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 to be eligible for QualityPath’s enhanced benefits. If the patient does not inform The Alliance, employers do not receive QualityPath pricing.
Adapting Plan Design for Health Savings Accounts (HSAs)
100 percent coverage after the deductible is paid and a cash reimbursement worth at least $100, which may be either funded in the HSA account or paid directly to the patient.
100 percent coverage after the deductible is paid and a cash reimbursement worth at least $1,000, which may be either funded in the HSA account or paid directly to the patient.
All other plan design requirements apply to plans with HSAs.
Optional Enhancements that are Recommended but Not Required
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).
- Per-diem travel allowances.
Eligibility and 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.
- 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.
- Pre-operative visits and related tests are covered at 100 percent if the patient chooses not to have surgery due to shared decision-making with a designated QualityPath
- QualityPath can be extended to employees outside The Alliance service area if your third party administrator (TPA) can support it. Talk to your Member Services Representative to learn more.