The Affordable Care Act (“ACA”) prohibits employers from
discriminating between employees based on health status for purposes of
eligibility, benefits, or premiums. In June, the Department of Treasury,
Department of Labor, and Department of Health and Human Services issued final
regulations regarding workplace wellness programs. The new regulations allow an
employer to implement a workplace wellness program, notwithstanding the fact
that the employer will provide certain benefits to employees who do participate
in the wellness program but not to employees who do not participate -- so long as the
program meets certain conditions.
The requirements that will apply to a wellness program
depend on the type of the wellness program. The new regulations divide wellness
programs in to three categories:
- Participatory
Wellness Programs: These programs reward participants for participating in a
health-promoting activity such as joining a gym, completing a diagnostic
testing or health coaching program, or scheduling regular preventative care
appointments, without consideration of whether the participant meets any
specific health-related standard.
- Activity-Only
Wellness Programs: These programs reward participants for engaging in
activities related to a specific health standard, such as walking or exercising
a certain number of times per month. Rewards under activity-only wellness
programs are not based on the specific health outcome of such activities.
- Outcome-Based
Wellness Programs: These programs reward participants for achieving a specific
health standard or outcome, such as losing thirty pounds or testing at a
“normal” level on biometric tests such as blood pressure or BMI.
Employers offering only participatory wellness programs must
offer participation to all similarly situated individuals, regardless of their
health status. Employers offering activity-only or outcome-based programs must
meet additional requirements because the risk of discrimination between
employees based on health status is greater under those programs. Those
requirements are, generally:
- Frequency
of Opportunity to Qualify: The wellness program must allow participants to
qualify for the program reward at least once each year.
- Size
of Reward: The total reward resulting from satisfying health-contingent
standards under the program may not exceed 30% of the total insurance premium
for the person(s) covered under the program. This percentage is increased to
50% to the extent that the increase in the reward is the result of a program
related to smoking cessation.
- Reasonable
Design: The program must be reasonably designed to promote health or
prevent disease. This requirement considers a variety of program-specific
facts, including the burden to participants, the likelihood of program success,
and whether the program is a cover for discriminating between employees based
on health status.
- Reasonable
Alternative Standard: The program must provide a reasonable alternative
standard for any individual who cannot meet a required standard or has been
advised by a doctor that it would be dangerous to try to meet the standard.
- Notice
of Availability of Reasonable Alternative Standard: In addition to offering
a reasonable alternative, the program must notify participants, in all
materials describing the terms of the wellness program, that reasonable
alternatives are available and the program will respect the recommendations of
a participant’s primary physician.
These new requirements take effect beginning January 1,
2014. Unlike other provisions under the ACA, the employer wellness program
requirements apply to both grandfathered and non-grandfathered plans. As a
result, all employers currently offering a wellness program or considering
implementing a wellness program should review their wellness program to make
sure it complies with the new regulations.
This posting is intended to provide a general overview of
the requirements under the new wellness program regulations, and is by no means exhaustive. You should contact
an experienced benefits attorney for guidance on
how the new requirements apply to you.