What New Health Promotion Rules Mean for You.
Compliance with health insurance portability and accountability act (HIPAA) non-discrimination rules is a large 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 U.S. Treasury Department. The rules themselves haven’t changed, but they’ve been clarified. Here’s what you need to know -
â..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 health insurance portability and accountability act (HIPAA) -
o reimbursing all or a portion of the cost of health club membership
o financial rewards for undergoing health risk appraisals so long as the reward is based on participation rather than test results
o encouraging preventive care by waiving co-pays or deductibles for these services (i.e., well-baby visits or prenatal care)
o reimbursing workforce for the cost of use of tobacco-cessation programs without regard to the result, and
o offering rewards tied to personnel attending a monthly health education seminar or working with a wellness Coach.
Conditional rewards OK ifâ..
But what when 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 health 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 -
o The reward can’t exceed 20 percent of the cost of employee-only (or, if you allow dependents to participate, employee-plus-dependent) coverage under your health plan.
o The standards must 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 personnel (e.g., rewards for all non-diabetics).
o Participants must’ve the opportunity to qualify for the reward at least once each year (e.g., a smoker who fails to quit this year gets another chance next year).
o Rewards ought to be available to all “similarly situated person.” In other words, you can’t make a company-compensated weight control program available to certain staff but not others.
When, for medical reasons, it’s unreasonably difficult for an individual to satisfy conditions that are otherwise reasonable, you have to offer an alternative. Example - A pregnant employee may not be able to meet certain standards, so you have to offer her an alternative.
Negative incentives violate health insurance portability and accountability act (HIPAA)
So what’s not permitted under HIPAA’s non-discrimination rules? Anything that punishes individuals for their health conditions or health risks.
The rules prohibit companys from charging different premiums, contributions, co-pays or deductibles based on personal health factors such as obesity or smoking. Notwithstanding, it’s OK to reimburse these expenses based on someone’s participation in your health promotion program, without regard to success.
In addition, the feds have added an important new non-discrimination rule - Employers’ heath plans can’t deny benefits for treatment of injuries resulting from a health condition, even when the condition wasn’t diagnosed before the injury.
For example, some healthcare programs have a “suicide exclusion” that denies payment for treating self-inflicted wounds from a suicide try. Now let’s suppose the staff member suffers from clinical depression. Even if the depression was undiagnosed prior to the suicide try, it’s illegal for your plan to deny benefits to this staff member.