offering wellness programs after final regulations

Download Offering Wellness Programs After Final Regulations

Post on 12-Nov-2014

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This webinar reviews the requirement that an employer must meet under the new final HIPAA regulations. It will also cover other compliance issues dealing with taxation, ERISA and ADA.

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  • 1. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC
  • 2. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Compliance Issues under Wellness Programs By Larry Grudzien Attorney at Law 2
  • 3. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Agenda Review requirements under HIPAA Review Field Assistance Bulletin 2008-02 Review requirements under GINA Review requirements ADA Developments Take your questions 3
  • 4. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Wellness Program Requirements Under HIPAA 4
  • 5. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Interim final nondiscrimination regulations published in 2001 along with proposed wellness regulations. Final nondiscrimination rules and wellness program rules published 12/13/2006. final regulations effective for plan years beginning on and after 7/1/2007. New proposed regulations were released in November 2012. New final regulations were released in June 2013, which are effective in 2014. Rules are a joint effort of Treasury, Labor & HHS 5 Guidance Through the Years
  • 6. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Group health plans and insurers cannot discriminate against participants on the basis of any health factors. Discrimination encompasses: Eligibility: Enrollment, effective date, waiting periods, benefits. Premiums or contributions: Including discounts, rebates or differential mechanisms. But wellness plans are an exception. 6 Fundamental Principles
  • 7. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Violations of HIPAA nondiscrimination rules can result in: Code-based excise taxes of $100 per day per person per failure. DOL audit and civil action to enforce rules. Private right of action under ERISA 502 to enforce rules. 7 Fundamental Principles
  • 8. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Wellness Programs In General Guidance is provided in the final regulations for evaluating the permissibility of wellness programs under HIPAAs nondiscrimination requirements. Separate requirements apply under HIPAA depending upon whether the wellness program is: a health-contingent program (it provides a reward that is contingent on satisfaction of a health-contingent standard related to a health factor); or a participation-only program (it simply rewards participation in the program regardless of whether the individual satisfies a health-contingent standard related to a health factor). 8
  • 9. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC In a nutshell, if the program is health-contingent-based, the final regulations require the program to meet five specific conditions. If the program is participation-only, the final regulations require only that the program be available to all similarly situated individuals. 9 Wellness Programs In General
  • 10. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC A wellness program can take many forms (and might not even be called a wellness program), but its defining feature is usually a reward to encourage healthier lifestylesreduced premiums or co-pays in exchange for quitting smoking or reducing bad cholesterol levels, for example. Employers and insurers hope that by encouraging healthier lifestyles, health care costs can be contained or reduced. HHS has recommended that employers consider providing health promotion or wellness programs and disease management programs for employees as part of their health benefits. 10 Wellness Programs In General
  • 11. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Some wellness programs simply make their services available to those who wish to use them, but others target individuals who have specific medical conditions, such as asthma or diabetes, and make special help available to them. For example, the program may provide case managers who will help monitor compliance with medication protocols and schedule appointments with physicians or therapists; special educational opportunities; newsletters; and discounts on co-pays for required medications. 11 Wellness Programs In General
  • 12. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC The rewards offered by wellness programs can vary greatly, from T-shirts or water bottles to significant reductions in premiums, co-pays, or deductibles. In addition, the Health-Contingents necessary to qualify for the reward can vary greatly, from actually quitting smoking or lowering cholesterol to merely attending a smoking-cessation class or signing a certification that weekly exercise sessions have been completed. 12 Wellness Programs In General
  • 13. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC HRAs are often used by wellness programs to identify the individuals who can benefit the most from the wellness programs and who represent the greatest opportunities for cost containment. In addition, health risk assessments can be used by plan participants and beneficiaries to identify areas of possible concern and to set health- related goals. 13 Health Risk Assessments (HRAs)
  • 14. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC HRAs can also be much more hands-on and can range from basic screenings at the employees worksite (e.g., blood pressure, cholesterol, body mass index, blood sugar, and bone density) to complete physical examinations at a doctors office or a hospital. Often the initial HRA is used as a baseline against which subsequent assessments are measured to track progress toward health-related goals. An employer cannot make taking HRAs mandatory to receive coverage. 14 Health Risk Assessments (HRAs)
  • 15. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Wellness programs that do not condition eligibility for a reward upon a participants ability to meet a health Health-Contingent are permissible if participation in the programs is available to all similarly situated individuals. Examples of participation-only programs include: incentives to participate in a health fair or testing (regardless of outcome); waiver of co-payment/deductible for well-baby visits; reimbursement of health club membership; reimbursements for smoking cessation programs (regardless of outcome); and a program that rewards employees who complete a health risk assessment, without further action related to health issues identified as part of the health risk assessment. 15 Participation-Only Programs
  • 16. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Health-contingent wellness programs require individuals to satisfy a health-contingent standard related to a health factor as a condition for obtaining a reward. A reward includes both an incentive in the form of a reward (e.g., premium discount, waiver of cost sharing amount, an additional benefit or any financial or other incentive) and an incentive in the form of avoiding a penalty (e.g., the absence of a premium surcharge or other financial or nonfinancial disincentive). 16 Health-Contingent-Based Programs
  • 17. Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC Health-contingent programs are further divided into activity-only programs and outcome-based programs: Activity-only programs require individuals to complete an activity related to a health factor to obtain the reward, but the activity need not result in a specific health outcome. For example, the employer may provide a reward for a walking, diet, or exercise program. Outcome-based programs require individuals to attain or maintain a specific health outcome in order to obtain the reward. For example, an employer could provide a reward for not smoking, for obtaining a certain result on a biometric screening, or for maintaining a certain body mass index (BMI). 17 Health-Contingent-Based Programs

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