FAQ: Can a participatory wellness program require a specific outcome?
No. Participatory wellness programs do not require a specific outcome in order for a participant to receive a reward.
Wellness programs have grown in popularity since passage of the Affordable Care Act but they have been around for some time. Individuals are motivated to participate in wellness programs to receive a reward, such as a discount or rebate of a premium or contribution, a waiver of all or part of cost-sharing, or an additional benefit.
The IRS issued proposed rules in 2006 and more guidance in 2013. The IRS has divided wellness programs into two categories: (1) programs that either do not require an individual to meet a standard related to a health factor to obtain a reward or that do not offer a reward at all; and (2) programs that require individuals to satisfy a standard related to a health factor to obtain a reward. The first category is commonly known as participatory wellness programs. The second category is known as health-contingent wellness programs.
Participatory wellness programs
Participatory wellness programs encompass a wide range of activities. One of the most common type of participatory wellness program is a program that reimburses all or part of the cost of a gym membership. A program that encourages individuals to complete a health risk assessment regarding current health status, without any further action with regard to the health issues identified as part of the assessment is another example of a participatory wellness program.
All of these examples have a similar feature. They do not link a reward to certain outcomes, activities or certain results. An individual may take advantage of the gym membership and rarely go. An individual may attend a health risk assessment and elect not to take action on any findings from that assessment.
Participatory wellness programs must be available to all similarly-situated individuals. Participatory wellness programs also must comply with other federal laws.
Health contingent programs
In contrast to participatory programs, health-contingent programs are linked to a certain activity or result. Some threshold or standard must be attained. These types of programs would generally run afoul of laws prohibiting health plans from treating employees differently based on the status of their health. The Affordable Care Act and other laws have created some exceptions for activity-only programs and outcome-based programs.
A gym membership can be a health-contingent program if it requires an individual to participate for a certain number of sessions or obtain a specific health outcome. Tobacco cessation programs are a common example of outcome-based wellness programs. Participants must attain a specific health goal, such as ceasing to use tobacco products. A health screening that requires participants to take a health or fitness course is another example of a health-contingent program. For example, a cholesterol awareness program may require a certain cholesterol count in order for the participant to receive a reward.
Health contingent programs must satisfy five requirements: (1) Size of award; (2) Frequency of opportunity to take advantage of the program; (3) Reasonableness of design; (4) Uniform availability and reasonable alternatives; and (5) Notice to employees. After January 1, 2014, the maximum size of a health-contingent reward is 30 percent of the total cost of coverage (50 percent for health-contingent programs designed to prevent or reduce tobacco). Of significant importance is the requirement that any reward be available to all similarly-situated individuals. If, for example, an individual cannot meet the threshold or standard to receive a reward, there must be a reasonable alternative.
In addition to the Affordable Care Act, other federal laws, as well as state laws, impact wellness programs. Please contact our office if you have any questions about wellness programs under ACA guidelines.
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