Regulators Issue Guidance About Wellness Programs

The proposed rules reflect the changes to existing wellness provisions made by the Affordable Care Act and encourage appropriately designed, consumer-protective wellness programs in group health coverage. The proposed rules would be effective for plan years starting on or after January 1, 2014.

The guidance continues to support workplace wellness programs, including “participatory wellness programs” which generally are available without regard to an individual’s health status. These include, for example, programs that reimburse for the cost of membership in a fitness center; that provide a reward to employees for attending a monthly, no-cost health education seminar; or that provides a reward to employees who complete a health risk assessment without requiring them to take further action.  

In order to protect consumers from unfair practices, the proposed regulations would require health-contingent wellness programs to follow certain rules, including: 

• Programs must be reasonably designed to promote health or prevent disease. To be considered such, a program would have to offer a different, reasonable means of qualifying for the reward to any individual who does not meet the standard based on the measurement, test or screening. Programs must have a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals. 
• Programs must be reasonably designed to be available to all similarly situated individuals. Reasonable alternative means of qualifying for the reward would have to be offered to individuals whose medical conditions make it  unreasonably difficult, or for whom it is medically inadvisable, to meet the specified health-related standard. 
• Individuals must be given notice of the opportunity to qualify for the same reward through other means. These proposed rules provide new sample language intended to be simpler for individuals to understand and to increase the likelihood that those who qualify for a different means of obtaining a reward will contact the plan or issuer to request it. 

The proposed rules also implement changes in the Affordable Care Act that increase the maximum permissible reward under a health-contingent wellness program from 20% to 30% of the cost of health coverage, and that further increase the maximum reward to as much as 50% for programs designed to prevent or reduce tobacco use.