Harvard Pilgrim Fitness Reimbursement Form printable pdf download

Harvard Pilgrim Fitness Reimbursement Form

Please read the instructions below, then proceed to fill out the Fitness Reimbursement Form on page 2.

Mailing Instructions

Keep copies of all documentation before sending in your Fitness Reimbursement Form.

Please enclose copies of the following:

1. Copy of your health club or fitness facility membership agreement

2. Completed Fitness Reimbursement Form

3. Copy of at least four months of receipts in a calendar year (cash/check/credit/electronic) for membership fees clearly

documenting your name and the facility name. Fees must equal or exceed amount being claimed.

Mail to:

Harvard Pilgrim Health Care

P. O. Box 9185

Quincy, MA 02269

Commonly Asked Questions and Answers

How do I qualify for a reimbursement?

How much can I claim for reimbursement?

• If enrolled through an employer, the employer must offer

• Reimbursement for most plans is up to $150 per calendar

Harvard Pilgrim’s fitness reimbursement program. If en-

year (e.g., January–December) per family, in total for

rolled through a Harvard Pilgrim Buy Direct plan, you’ll be

health club/fitness facility membership fees for the subscriber

eligible after four months in the plan.

and/or their dependents.

• Health club or fitness facility membership must be for at

• Reimbursement for some employer groups may differ.

least four months in a current calendar year.

• Per the Patient Protection and Affordable Care Act, as of

• Current Harvard Pilgrim membership must be at least four

January 1, 2014, coverage for some small groups, and

months in a calendar year and must coincide with four

individuals who purchase plans directly from Harvard

months of health club or fitness membership.

Pilgrim, includes fitness reimbursement that is different

than the standard benefit. Please see your Benefit Handbook

When can I submit my Fitness Reimbursement Form?

and Schedule of Benefits for details.

Starting with May 1 of the current calendar year and when

What happens once I submit the Fitness Reimbursement

you have met the above-stated criteria.

Form?

Which fitness facilities qualify?

• Reimbursement checks will be mailed and made payable to

• Full-service health/fitness clubs that have cardiovascular

the Subscriber only at the Subscriber’s address of record.

and strength-training equipment and facilities for exercising

No alternative address will be accepted.

and improving physical fitness. Validation as full-service is

• If you believe your current address is different than the ad-

subject to approval by Harvard Pilgrim.

dress of record in Harvard Pilgrim’s systems, please contact

• Fitness studios/facilities that offer yoga, Pilates, Zumba,

us prior to submitting your Fitness Reimbursement Form.

aerobic/group classes, indoor cycling/spinning classes,

• Please allow up to 8 weeks for processing.

kickboxing, CrossFit, strength training, tennis, indoor

rock climbing and personal training (taught by a certified

instructor).

• Note: The following are not eligible for reimbursement:

fees you pay for group classes or personal training outside

of a fitness facility/studio, and health club initiation fees or

costs that you pay for instructional dance studios, country

clubs, social clubs (such as ski, riding or hiking clubs), spas,

gymnastics facilities, martial arts schools, pool-only facili-

ties, road race fees, sport camps, ski passes, sports teams or

leagues, and school sports athletic user fees.

Page 1 of 2

Harvard Pilgrim Health Care includes Harvard Pilgrim Health Care,

Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England and HPHC Insurance Company.

cc2812 4_16

Harvard Pilgrim Fitness Reimbursement Form

Related Articles

Related forms

Related Categories