What New Wellness Rules Mean for You.

Compliance with HIPAA non-discrimination rules is a big challenge for wellness programs. the old rules were unclear about which incentives passed muster.

That’s all changed, with the rules established earlier this year by the DOL and USA  Treasury Department. the rules themselves haven’t changed, but they’ve been clarified. Here’s what you need to know -

‘Participation incentives’ are fine

As long as you structure incentives as rewards for wellness participation, the new rules provide a lot of freedom. All of these are fine under HIPAA -

• reimbursing all or a portion of the cost of fitness club membership

• financial rewards for undergoing health risk (assessment|appraisal}s so long as the reward is based on participation rather than test results

• encouraging preventive care by waiving co-pays or deductibles for these services (i.e., well-baby visits or prenatal care)

• reimbursing staff members for the cost of smoking-cessation programs without regard to the result, and

• offering rewards tied to employees attending a monthly health education seminar or working with a health coach.

Conditional rewards OK if…

But what if you want to make the reward conditional on participants meeting specific health goals? Example -  Staff Members who achieve a cholesterol count under 200 get a 20% reduction in the cost of their medical plan contributions pending results of an annual cholesterol test.

The feds say it’s OK under health insurance portability and accountability act (HIPAA) to do this, too, but your plan must meet five additional requirements -

• the reward can’t exceed 20 percent of the cost of employee-only (or, when you allow dependents to participate, employee-plus-dependent) coverage under your health plan.

• the standards ought to be reasonable (e.g., you can’t limit rewards to folks who can run a marathon). the rewards also can’t be used as a backhanded way to adversely single out certain workers (e.g., rewards for all non-diabetics).

• Participants must’ve the opportunity to qualify for the reward at least once per year (e.g., a smoker who fails to quit this year gets another chance next year).

• Rewards should be available to all “similarly situated individuals.” In other words, you can’t make a company-paid weight control program available to certain employees but not others.

When, for medical reasons, it’s unreasonably difficult for an individual to satisfy conditions that are otherwise reasonable, you must offer an alternative. Example -  A pregnant employee might not be able to meet certain standards, so you must offer her an alternative.

Negative incentives violate HIPAA

So what’s not permitted under health insurance portability and accountability act (HIPAA)’s non-discrimination rules? Anything that punishes people  for their medical conditions or health risks.

The rules prohibit employers from charging different premiums, contributions, co-pays or deductibles based on personal health factors such as obesity or use of tobacco. Notwithstanding, it’s OK to reimburse these expenses based on someone’s participation in your wellness program, without regard to success.

In addition, the feds have added an important new non-discrimination rule -  Companys’ health plans can’t deny benefits for treatment of injuries resulting from a medical condition, even if the condition wasn’t diagnosed before the injury.

For example, some health plans have a “suicide exclusion” that denies payment for treating self-inflicted wounds from a suicide try. Now let’s suppose the employee suffers from clinical depression. Even when the depression was undiagnosed prior to the suicide try, it’s illegal for your plan to deny benefits to this employee.