EBSA Issues- Guidance on Health Plan Wellness & Disease Management Practices Subject to HIPAA Nondiscrimination Rules

Cynthia Stamer
February 19, 2008 — 2,048 views  
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On February 14, 2008, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) released guidance to the agency’s national and regional offices on the types of health promotion and disease management programs required to comply with final regulations relating to the application of the nondiscrimination requirements of the Health Insurance Portability and Accountability Act (HIPAA) to wellness and disease management programs. The guidance is particularly timely in light of the growing interest of employers and health plans in the use of disease management and wellness programs to manage health care costs and promote health care quality. HIPAA’s nondiscrimination provisions generally prohibit a group health plan or group health insurance issuer from denying an individual eligibility for benefits based on a health factor and from charging an individual a higher premium than a similarly situated individual based on a health factor. Health factors include: health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability. An exception provides that plans may vary benefits (including cost-sharing mechanisms) and premiums or contributions based on whether an individual has met the standards of a wellness program that complies with paragraph (f) of the regulations. On December 13, 2006, the Departments of Labor, the Treasury, and Health and Human Services published joint final regulations on these nondiscrimination provisions including the wellness and disease management arrangements that HIPAA-covered plans may use without violating the nondiscrimination rules. These final HIPAA nondiscrimination rules apply to group health plans and group health insurance issuers on the first day of the plan year beginning on or after July 1, 2007. Accordingly, for calendar year plans, the new regulations began to apply on January 1, 2008. In Field Assistance Bulletin (FAB) 2008-02, the EBSA provides a checklist designed to help its staff determine which health promotion or disease prevention programs offered by a group health plan must comply with the those regulations and how to determine whether such programs comply with the regulations. The checklist includes examples and tips on the applicability of the wellness program rules and, if the rules apply, the five compliance criteria. To review a copy of this checklist, go to http://www.dol.gov/ebsa/regs/fab2008-2.html. If you have any questions about regarding this filing requirement, or if we may be of assistance with regard to any other employee benefit or employment related matters, please do not hesitate to contact Cynthia Marcotte Stamer at 972.419.7188.

Cynthia Stamer


Cynthia Marcotte Stamer, is nationally and internationally recognized for her work assisting businesses, governments, and other entities to develop creative strategies for dealing with employee benefit and related human resources, insurance, health care and finance concerns. Ms. Stamer helps businesses design, administer and defend cost-effective employee benefit other human resources programs, policies and procedures to meet their budgetary and other business objectives.