2 Real World Examples of ACA-Compliant Wellness Programs

aca compliant wellness programs

BARB RAND
Compliance Advisor

Employers are striving to establish ACA-compliant wellness programs, but let's face it — the regulations are dense and confusing. Sometimes it's easier to understand a point when you have a good example.

Our recent webinar on wellness regulations under the ACA gave two great examples of ACA-compliant wellness programs (derived from the actual Affordable Care Act rules). The examples below are for outcome-based programs.

To refresh your memory, outcome-based wellness programs are one of two types of health-contingent wellness programs. (The other type of health-contingent programs are activity-only programs). Outcome-based programs require employees to reach or maintain a specific wellness goal (such as BMI, cholesterol level, non-tobacco using status, etc.) in order to get a reward.

Here are two examples that could apply to many different employers:

Example No. 1: Compliant Outcome-Based Wellness Program for Improving Cholesterol Count

All employees can earn a reward for meeting a specific cholesterol count (200 or lower). If an employee doesn't meet the cholesterol count, he and his doctor can develop an action plan that will enable him to receive the same reward. The action plan might include medication and additional screenings.

All plan materials describing the terms of the program include the following statement:

“Your health plan wants to help you take charge of your health. Rewards are available to all employees who participate in our Cholesterol Awareness Wellness Program. If your total cholesterol count is under 200, you will receive the reward. If not, you will still have an opportunity to qualify for the reward. We will work with you and your doctor to find a Health Smart program that is right for you.”

Moving on, when an employee receives notification that his cholesterol count is 200 or higher, the notification includes the following statement:

“Your plan offers a Health Smart program under which we will work with you and your doctor to try to lower your cholesterol. If you complete this program, you will qualify for a reward. Please contact us at [contact information] to get started.”

Example No. 2: Compliant Outcome-Based Wellness Program for Improving BMI

An employer sponsors a biometric screening program. Under the program, employees with a BMI of 26 or lower will receive a discount to the employee cost of health coverage. Employees who do not meet that target BMI window may get the same discount/reward by walking 150 minutes weekly. The walking alternative is an activity-based wellness program because the employer is asking employees to do something that may be more difficult for those employees with a health factor.

Some employees cannot comply with the walking program. The program may be unreasonably difficult because of a medical condition or because it's medically inadvisable for them to participate. These employees are given the same discount for satisfying a second alternative standard that is reasonable, not unreasonably burdensome or impractical to comply with, and is otherwise reasonably designed.

All plan materials describing the terms of the wellness program include the following statement:

“Fitness is easy! Start walking! Your health plan cares about your health. If you are considered overweight because you have a BMI of over 26, our Start Walking program will help you lose weight and feel better. We will help you enroll. (If your doctor says that walking isn't right for you, that's OK, too. We will work with you (and, if you wish, your own doctor) to develop a wellness program that is.)"

Employee John Smith is unable to hit the target BMI window of 26 or lower within the plan's time frame. He received compliant notification. It is unreasonably difficult for John to comply with the program because of a medical condition (he broke leg and is unable to walk.)

What's John's next move? John talks to his doctor, and he proposes to his employer an alternative program based on his doctor's recommendations. The plan administrators agree to make the same contribution discount available to John that's available to other co-workers who are participating in the BMI program or the alternative walking program. But John only gets the reward if he actually follows his doctor's recommendations.

For the full story on ACA-compliant wellness programs, please check out the recording of our webinar on wellness regulations under the ACA and download the slide deck. Click on the button below to get started.