Decoding Reasonable Alternative Standards for Wellness Programs

Reasonable Alternative Standards for Wellness Programs

BARB RAND
Compliance Advisor

The Affordable Care Act shook up who gets health coverage and how they get that coverage. It also modified the framework for wellness programs, tools used by many employers to improve the health of their employee population — and to reap health care savings for fitter, happier, and healthier workers.

Health-contingent wellness programs, which base rewards for employees on either activities or outcomes, now have new guidelines for reasonable alternative standards. According to the new governance,

"These final regulations also do not require plans and issuers to establish a particular reasonable alternative standard in advance of an individual's specific request for one, as long as a reasonable alternative standard is provided by the plan or issuer (or the condition for obtaining the reward is waived) upon an individual's request. Plans and issuers have flexibility to determine whether to provide the same reasonable alternative standard for an entire class of individuals (provided that it is reasonable for that class) or provide the reasonable alternative standard on an individual-by-individual basis, based on the facts and circumstances presented."

For some employees, it may not be in the best interest of their health (for instance, a heart or seizure condition) to chase a particular goal. Reasonable alternative standards for wellness programs exist to ensure that all employees, regardless of medical status, have the opportunity to earn a reward for achieving modified health goals.

Two Different Reasonable Alternative Standards for Wellness Programs

Because there are two flavors of health-contingent wellness programs — activity-only and outcome-based — reasonable alternative standards are different for each. (If you need a refresher, you can discover the different types of wellness programs under the new rules in a previous blog post.)

For activity-based programs, a reasonable alternative is allowed for anyone for whom it is medically inadvisable to try to satisfy the health goal. Let's say an activity-based program calls for employees to log 10,000 steps per day for a reward. The doctor of an employee might discourage the 10,000 mark because of an existing medical condition. Under the final rule for wellness programs, if an employee would like to receive a reward but cannot complete the activity, the employee may request a reasonable alternative for obtaining the reward; perhaps the employee could log fewer steps.

In an outcome-based program, participants should achieve a defined target health outcome to receive a reward. Achieving the target usually is verified by a third party or wellness vendor if personal health information (PHI) is involved. Tobacco cessation is a common target health outcome, and completion of a tobacco cessation program is a common reasonable alternative standard for obtaining a reward.

When Employers Need to Listen to a Doctor

A recommendation by an employee's personal physician may be considered when determining reasonable alternative standards for activity-based wellness programs. A doctor specifically can suggest substitute physical activity that is safe for the employee.

To discover more about reasonable alternative standards for wellness programs, click the button below to access the slide deck and recording from HNI's webinar, "Know the Rules: Wellness Regulations Under the ACA."