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. Annual Qualification. The program must give individuals an opportunity to qualify for the reward once per year. This requirement is generally the same as under the existing rules.
2. Reward Limit. The reward, together with the reward for other HC programs, must not exceed 30 percent of the cost of coverage. This percentage is increased to 50 percent if the program is designed to prevent or reduce tobacco use. Currently, the existing rules limit the amount of the reward to 20 percent of the cost of coverage.
3. Reasonable Alternative. The program must provide a reasonable alternative standard for any individual for whom it is unreasonably difficult due to a medical condition, or medically inadvisable, to satisfy the otherwise applicable standard. This is the same requirement as under the existing rules; however, the proposed rule provides clarification regarding what is considered reasonable. All the facts and circumstances are considered in determining whether an alternative is reasonable.
The proposed rule provides the following guidelines for reasonable alternatives:
(i) If the reasonable alternative standard is completing an educational program, the plan must make the educational program available instead of requiring a member to find a program on his or her own and may not require a member to pay for the cost of the program.
(ii) If the reasonable alternative standard is a diet program, plans are not required to pay for the cost of food but must pay any membership or participation fee.
(iii) If the reasonable alternative standard is compliance with recommendations of a medical professional who is an employee or agent of the plan, and a member's personal physician states that the plan's recommendations are not medically appropriate for that member, the plan must provide a reasonable alternative standard that accommodates the recommendations of the member's personal physician with regard to medical appropriateness. A plan may impose standard cost-sharing for medical items and services furnished according to the physician's recommendations.
As under the existing rules, a plan may request verification, such as a physician's statement, that it is unreasonably difficult or medically inadvisable for the individual to meet the standard. However, the proposed rule adds an additional requirement that a plan may only seek verification if "reasonable under the circumstances". The proposed rule indicates that it would not be reasonable for a plan to seek verification of a claim that is obviously valid based on information known to the plan.
4. Reasonable Design. The program must be reasonably designed to promote health and prevent disease. This is the same requirement as under the existing rules, however, the proposed rule provides clarification regarding what is considered a reasonably-designed program. All the facts and circumstances are considered in determining whether a program is reasonably designed. In addition, the proposed rule states that to be considered reasonably designed, the program must provide a different reasonable means to any individual who cannot meet the standard if the standard is based on the results of a screening or test.
5. Disclosure Requirement. All materials describing the program must disclose the availability of other means of qualifying for a reward or the possibility of waiving the applicable standard. The plan materials are not required to describe specific reasonable alternative standards nor is disclosure required where the program is just merely mentioned without describing its terms. This is a similar disclosure requirement as under the existing rules, however, notice must now be provided that a reasonable means is available to all individuals as opposed to those with medical conditions.