Yes. HC programs must meet the following five requirements, which are generally the same requirements under existing law with some changes and additional clarification:
1. Frequency of Opportunity to Qualify. Both programs must give individuals eligible for the program an opportunity to qualify for the reward at least once per year.
2. Size of Reward. The reward for both programs, together with the reward for other health-contingent wellness programs with respect to the plan, must not exceed 30 percent of the total cost of coverage, except this percentage is increased to 50 percent to the extent that the wellness program is designed to prevent or reduce tobacco use.
3. Reasonable Design. The program must be reasonably-designed to promote health or prevent disease. A program satisfies this standard if it has a reasonable chance of improving the health of, or preventing disease in, participating individuals, and it is not overly burdensome, is not a subterfuge for discriminating based on a health factor and is not highly suspect in the method chosen to promote health or prevent disease. This determination is based on all the relevant facts and circumstances. To ensure that an outcome-based wellness program is reasonably designed, it must provide a reasonably alternative standard to qualify for the reward to any individual who does not meet the initial standard based on a measurement, test or screening that is related to a health factor.
4. Reasonable Alternative Standard.The full reward must be available to all similarly situated individuals. With respect to an activity-only wellness program, this standard is met if the program provides a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining a reward to any individual for whom, for that period, it is either unreasonably difficult due to a medical condition to meet the otherwise applicable standard, or for whom it is medically inadvisable to attempt to satisfy the otherwise applicable standard. Under this program type, if reasonable under the circumstances, it is permissible for a plan or issuer to seek verification, such as a statement from an individual’s personal physician, that a health factor makes it unreasonably difficult for the individual to satisfy, or medically inadvisable to attempt to satisfy the otherwise applicable standard.
With respect to an outcome-based wellness program, this requirement is met if the program provides a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward to any individual who does not meet the initial standard based on a measurement, test or screening that is related to a health factor. Under this program type, it is not permissible for a plan or issuer to seek verification, such as a statement from an individual’s personal physician, that a health factor makes it unreasonably difficult for the individual to satisfy, or medically inadvisable for the individual to attempt to satisfy, the otherwise applicable standard.
All of the facts and circumstances are taken into account in determining whether a plan or issuer has provided a reasonable alternative standard, including but not limited to the following:
(i) If the reasonable alternative standard is completion of an educational program, the plan or issuer must make the educational program available instead of requiring an individual to find such a program unassisted, and may not require an individual to pay for the cost of the program.
(ii) The time commitment required must be reasonable (i.e. requiring attendance nightly at a one-hour class would be unreasonable).
(iii) If the reasonable alternative standard is a diet program, the plan or issuer is not required to pay for the cost of food but must pay any membership or participation fee.
(iv) If an individual?s personal physician states that a plan standard (including, if applicable, the recommendations of the plan?s medical professional) is not medically appropriate for that individual, the plan or issuer must provide a reasonable alternative standard that accommodates the recommendations of the individual's personal physician with regard to medical appropriateness. Plans and issuers may impose standard cost sharing under the plan or coverage for medical items and services furnished pursuant to the physician?s recommendations.
To the extent that a reasonable alternative standard under either program is, itself, an activity-only wellness program, it must comply with the reasonable alternative standard requirements for this program type as noted above.
To the extent that the reasonable alternative standard is another outcomes-based program, it must comply with the reasonable alternative standard requirements of this program type as noted above and is subject to the following special rules. First, the reasonable alternative standard cannot be a requirement to meet a different level of the same standard without allowing for additional time to comply that takes into account the individual’s circumstances. Second, an individual must be given the opportunity to comply with the recommendations of the individual’s personal physician as a second reasonable alternative standard to meeting the reasonable alternative standard defined by a plan or issuer, but only if the physician joins in the request.
5. Notice of Availability of Reasonable Alternative Standard. The plan or issuer must disclose in all plan materials describing the terms of the activity-only wellness program the availability of a reasonable alternative standard to qualify for the reward (and, if applicable, the possibility of waiver of the otherwise applicable standard), including contact information for obtaining the reasonable alternative standard and a statement that the recommendations of an individual’s personal physician will be accommodated. For outcome-based wellness programs, this notice must also be included in any disclosure that an individual did not satisfy the initial outcome-based standard.