Health & Wellness
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Sweat Equity Program
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UnitedHealthcare New York
If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from
the program. In New York: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall
also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.
Reimbursement form
Please print
Member
1
information
Member first name: Member last name: Date of birth (month/day/year):
Are you the plan subscriber? (yes/no): If no, what is your relationship to the plan subscriber? (e.g., spouse, domestic partner):
Employer/company name: Group number: Member ID number:
Member street address:
City: State: ZIP code:
Sweat Equity program 6-month period
Start date: End date:
Completing and submitting this form
1. Use 1 form per member. Record the 50 fitness
facility visits and/or classes that you completed
in a 6-month period on the chart shown below.
Record only 1 session per day.
• The first date you put on the chart is the beginning of
your 6-month program
• Your program will end 6 months from this date. Do not
make entries for activity after your program end date.
• If you complete 50 qualifying workouts in less than
6 months, please do not submit your reimbursement
request early. We cannot accept reimbursement
requests before 6 months have passed.
• Instead of filling in the dates of your 50 workouts, you
can attach to this form one of the following documents:
– A computer printout of your visits to the fitness facility
and/or classes completed, including dates and the
name of the place
– Receipts that show the dates of your fitness facility visits
and/or classes, with the name of the place
Your documentation must include signatures from a facility
representative, class administrator or event coordinator, as
appropriate, to prove participation.
2. Attach proof of payment (e.g., receipt, payroll deduction,
automatic bank withdrawal statement) for the fitness facility
fee, as well as any money you paid for fitness classes and
events, during the 6-month period*
3. Enclose a copy of the brochure, flier or downloaded
website content that describes the cardio equipment at the
facility you used or the cardio benefits of the class or
organized group fitness event in which you participated
4. Mail documentation to:
UnitedHealthcare Sweat Equity Reimbursement Program
P.O. Box 740806
Atlanta, GA 30374
These documents must be mailed to us (postmarked)
no later than 180 days from your program end date.
Requests postmarked after this date won’t be reimbursed.
You have the option to make your Sweat Equity reimbursement
request online if you do not wish to make the request by mail.
To make the request online:
•
Sign in to myuhc.com®
• Click Claims & Accounts
• Click Submit a Claim
• On the Medical tile, click Start a claim and fill in the
required information
*
On your proof of payment, please be sure to cross out any personal
account ID information that’s not needed so it isn’t readable.
continued
Fitness events, facility visits and classes (record only 1 session per day)
Date (mm/dd/yyyy) Session type* Date (mm/dd/yyyy) Session type*
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*Indicate “F” for facility/gym; “C” for class including organized group events (e.g., marathon).
continued
continued
Fitness event, class, session, facility information
Organization name: Organization name (If second one was used):
Organization type: Organization type:
Address: Address:
City, State, ZIP code: City, State, ZIP code:
Telephone number: Telephone number:
Name of events, classes, sessions you participated in:
Fitness facility/instructor information
Facility employee/class instructor name: Organization name (If second one was used):
Signature: Date:
Instructor or other facility employee’s signature above constitutes agreement that the instructor/facility promotes cardio
wellness for members.
Member verification Equity Program
If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated
from the program. In New York: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information, or conceals
for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for
each such violation.
Signature: Date:
Exclusions and limitations
• Sweat Equity™ is a voluntary program. The information provided under this program is for general informational purposes
only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care
professional before beginning any exercise program and/or to determine what may be right for you.
• For this program, the use of “you” and “member” in communications refers to the UnitedHealthcare plan subscriber or the
subscriber’s covered spouse or domestic partner; no other dependents are eligible. For the subscriber’s spouse/domestic
partner to be eligible for this benefit, they must also be enrolled in the UnitedHealthcare product. The program may not be
available to all UnitedHealthcare plan subscribers and their spouses/domestic partners. Reimbursement is generally limited
to the lesser of $200 (subscriber)/$100 (covered spouse/ domestic partner) or the actual amount of the qualifying fitness
costs per 6-month period, but the reimbursement may vary by plan. Refer to your Certificate of Coverage or other governing
member document to determine eligibility, including your plan’s benefit and application deadlines.
• To be eligible for reimbursement under the program, the qualifying facility, class or organized group physical fitness event
(e.g., marathon) that you choose must be available to the general public and promote cardiovascular wellness, as determined
by us, and have staff supervision.
• You must be an active employee at the time of your application for reimbursement. You may submit an application for
reimbursement under the program once every 6 months. We will reimburse only those qualified visits, sessions or events that
were completed while you were a UnitedHealthcare member. We will not reimburse visits, sessions or events that occurred
before your coverage became effective or after your coverage terminates. Partial reimbursements will not be given for fewer
than 50 workouts in a 6-month period.
• You must hold an active fitness facility or class membership for the facility/class named in the request at the time of your
application for reimbursement.
• Memberships in tennis clubs, country clubs, social clubs, sports teams, weight loss clinics or spas or any other similar
organizations, leagues or facilities will not be reimbursed. We will not reimburse you for the purchase of lessons, equipment,
clothing, vitamins or other items or services that may be offered by the facility. Reimbursement is limited to actual workout
visits. Physical and rehabilitative therapies do not apply.
• Lifetime memberships are not eligible for reimbursement.
• If you paid for a full-year’s facility membership or class enrollment in advance, at the end of the first 6-month period for
which you are applying for reimbursement, submit the receipt along with the required documentation noted above for
reimbursement against half of the annual fee that you paid. Repeat this process at the end of your second 6-month period for
which you made a full-year’s payment, if you have met the requirements for another, consecutive reimbursement.
• Complete 1 form per member, for each 6-month period for which you are applying for reimbursement.
• We cannot accept requests for reimbursement before your 6-month program end date, even if you have completed the
required number of qualifying workouts before this date.
• If any information is missing from this form, incorrect or cannot be substantiated, the application for reimbursement will be
delayed or denied.
• If you are unable to meet the reimbursement requirements of this program, you might be able to earn the same reward a
different way. Call us at the toll-free phone number on your health plan ID card and we will work with you and, if necessary,
your doctor, to find another way for you to earn the same reward.
• Any information we collect in conjunction with this program is kept confidential according to HIPAA requirements and is
separate from and has no effect on a member’s medical benefits or premium.
Learn more
Call the phone number on your health plan ID card
1
On this form, the term “member” refers to the UnitedHealthcare plan subscriber of a fully insured UnitedHealthcare® medical
plan, as well as the subscriber’s covered spouse or domestic partner. For the spouse or domestic partner to be eligible for this
benefit, they must also be enrolled in the UnitedHealthcare product.
The total annual reward amount for your participation in incentive-based programs cannot exceed 30% of the cost of coverage.
Rewards may be taxable. You should consult with an appropriate tax professional to determine if you have any tax obligations from
receiving reimbursement under this program.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.
B2C EI2220250441.4 11/22 © 2022 United HealthCare Services, Inc. All Rights Reserved. 22-1512204 (UHC NY SG (1-100), UHC NY LG (101+), fully insured)
