Agencies Tackle Rewards in Health Care Plans

     WASHINGTON (CN) – A number of federal agencies published final regulations regarding rewards for wellness programs under the Affordable Care Act, including those that fight tobacco use and obesity.
     The Internal Revenue Service, Treasury Department, Employee Benefits Security Administration, Department of Labor, and the Centers for Medicare and Medicaid Services issued on Monday their final regulations governing wellness programs under group health care coverage.
     Before the Affordable Care Act, the 1996 Health Care Insurance Portability and Accountability Act (HIPAA) had provisions that prohibited group health plans and group insurance issuers from discrimination against people based on health factors.
     The Affordable Care Act amended the HIPAA non-discrimination and wellness provisions to, among other things, extend the protections against discrimination to the individual market.
     “The departments believe that appropriately designed wellness programs have the potential to contribute importantly to promoting health and preventing disease,” the agencies wrote in their final regulations.
     The agencies noted that each wellness program is unique, and they will likely issue future modifications as necessary.
     “The final regulations also reorganize the presentation of the steps a plan or issuer must take to ensure a wellness program: is reasonably designed to promote health or prevent disease; has a reasonable chance of improving the health of, or preventing disease in, participating individuals; is not overly burdensome; is not a subterfuge for discriminating based on a health factor; and is not highly suspect in the method chosen to promote health or prevent disease,” they wrote.
     Thus, wellness programs must offer “reasonable alternative standards” to broader groups of people as they relate to “activity-only” programs, such as health plans that require a person to be tobacco-free.
     The departments noted, regarding stopping tobacco use, that “overcoming an addiction sometimes requires a cycle of failure and renewed effort.”
     “For plans with an initial outcome-based standard that an individual not use tobacco, a reasonable alternative standard in Year 1 may be to try an educational seminar.”
     “An individual who attends the seminar is then entitled to the reward, regardless of whether the individual quits smoking. At the same time, in Year 2, the plan may require completion of a different reasonable alternative standard, such as a complying with a new recommendation from the individual’s personal physician or a new nicotine replacement therapy.”
     The departments also wrote that the same is true of other outcome-based standards, such as weight management.
     “For example, if a plan or issuer provides a walking program as a reasonable alternative standard to a running program, individuals for whom it is unreasonably difficult due to a medical condition to complete the walking program (or for whom it is medically inadvisable to attempt to complete the walking program) must be provided a reasonable alternative standard to the walking program.”

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