Wellness Program Compliance Checklist

Insert the first day of current plan year:
Is the date after July 1, 2007?      Yes/No Wellness program rules applicable July 1, 2007
Does plan have a wellness program?     Yes/No Wellness programs may also be called disease management program, smoking cessation program, or case management program.
Is program part of a group health plan?      Yes/No Subject to Part 7 of ERISA if part of group health plan
Does program discriminate based on a health factor? Yes/No A plan discriminates based on a health factor if it requires an individual to meet a standard related to a health factor in order to obtain a reward.
       What are Health-Status Related Factors? ·      Health Status
  ·      Medical Condition (Physical or Mental Illnesses)
  ·      Claims Experience
  ·      Receipt of Health Care
  ·      Medical History
  ·      Genetic Information
  ·      Evidence of Insurability (EOI) (Including Conditions Arising Out of Acts of Domestic Violence)
 

 

·      Disability

  ·      Any Other Health Status-Related Factor Determined Appropriate By Secretary Of HHS (Added Under HCR)
If you answered “No” to any of the above questions, stop. Plan does not maintain a program subject to group health plan wellness program rules.
 
If program discriminates based on a health factor, is program saved by benign discrimination provisions? Yes/No 29 CFR 2590.702(g) permits discrimination in favor of individual based on a health factor

If you answered “Yes” to the previous question, stop: No violations of wellness program rules.

If you answered “No” to the previous question: wellness program must meet these FIVE criteria.

Compliance Criteria
1.  Is amount of reward offered under plan limited to 20% of applicable cost of coverage? Yes/No 29 CFR 2590.702(f)(2)(i)
  Who is eligible to participate in the wellness  program? If only employees are eligible to participate, amount of reward must not exceed 20% of cost of employee-only coverage under plan. If employees and any class of dependents are eligible to participate, reward must not exceed 20% of cost of coverage in which employee and dependents are enrolled.
  Does the plan have more than one wellness program? 20% limitation on amount of reward applies to all of a plan’s wellness programs that require individuals to meet a standard related to a health factor.
2.  Is plan reasonably designed to promote health or prevent disease? Yes/No 29 CFR 2590.702(f)(2)(ii) Program must be reasonably designed to promote health or prevent disease.
3.  Are individuals who are eligible to participate given a chance to qualify at least once per year? Yes/No 29 CFR 2590.702(f)(2)(iii)

4.  Is reward available to all similarly situated individuals?

  Does program offer reasonable alternative standard? 

Yes/No

29 CFR 2590.702(f)(2)(iv) Reward be available to all similarly situated individuals.

Component of meeting criterion is that program must have a reasonable alternative standard (or waiver of otherwise applicable standard) for obtaining reward for any individual for whom, for that period:

·       It’s unreasonably difficult due to medical condition to satisfy otherwise applicable standard; or

·       It is medically inadvisable to attempt to satisfy otherwise applicable standard.

It’s permissible for plan or issuer to seek verification, such as a statement from the individual’s physician, that a health factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.

5.  Does plan disclose availability of reasonable alternative in all plan materials describing the program? Yes/No

29 CFR 2590.702(f)(2)(v) Plan or issuer must disclose availability of reasonable alternative standard in all plan materials describing program. If plan materials merely mention that program is available, without describing its terms, this disclosure is not required.

This sample can be used to satisfy this requirement: “If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under this program, call us at [insert telephone number] and we will work with you to develop another way to qualify for the reward.”

If you answered “Yes” to all of the 5 questions on wellness program criteria: No violations of the HIPAA wellness program rules.

 

If you answered “No” to any of the 5 questions on wellness program criteria: Plan has a wellness program compliance issue.

 

Violation of the general benefit discrimination rule (29 CFR 2590.702(b)(2)(i))

If the wellness program varies benefits, including cost-sharing mechanisms (such as deductible, copayment, or coinsurance) based on whether an individual meets a standard related to a health factor and the program does not satisfy the requirements of 29 CFR 2590.702(f), the plan is impermissibly discriminating in benefits based on a health factor. The wellness program exception at 29 CFR 2590.702(b)(2)(ii) is not satisfied and the plan is in violation of 29 CFR 2590.702(b)(2)(i).

 

Violation of general premium discrimination rule (29 CFR 2590.702(c)(1))

If the wellness program varies the amount of premium or contribution it requires similarly situated individuals to pay based on whether an individual meets a standard related to a health factor and the program does not satisfy the requirements of 29 CFR 2590.702(f), the plan is impermissibly discriminating in premiums based on a health factor. The wellness program exception at 29 CFR 2590.702(c)(3) is not satisfied and the plan is in violation of 29 CFR 2590.702(c)(1).

 

 

 

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