A wellness program which contains any condition for obtaining a reward that is premised on an individual satisfying a standard that is associated with a health status related factor does not violate this subchapter so long as the requirements of paragraphs (1) - (6) of this section are met.

1. (1) For a group health benefit plan, the reward for the wellness program, coupled with the reward for other wellness programs offered under the same plan and which also require satisfaction of a standard associated with a health status related factor, must not exceed in total value 20 percent of the cost of employee-only, or member-only, coverage under the plan. However, if, in addition to employees or members, any class of dependents--such as spouses or spouses and dependent children--may participate in the wellness program, the reward must not exceed 20 percent of the cost of the coverage in which an employee, or member, and any dependents are enrolled.

   1. (A) For purposes of this section, the cost of coverage is determined based on the total amount of employer and employee contributions, or member contributions, for the benefit package under which the employee or member is, or the employee, or member, and any dependents are, receiving coverage.
   2. (B) A reward can be in the form of a discount or rebate of a premium or contribution; a waiver of all or part of a cost-sharing mechanism such as deductibles, copayments, or coinsurance; the absence of a surcharge; or the value of a benefit that would otherwise not be provided under the plan.
2. (2) The program must meet the criteria set out in §21.4705 of this subchapter (relating to Wellness Programs General Provisions).
3. (3) The program must give individuals eligible for the program the opportunity to qualify for the reward under the program at least once per year.

4. (4) The reward under the program must be available to all similarly situated individuals.

   1. (A) A reward under this subchapter is available to all similarly situated individuals for a period so long as the program allows, at a minimum:

      1. (i) a reasonable alternative standard, or waiver of the otherwise applicable standard, for obtaining the reward for any individual for whom, for that period, it is unreasonably difficult due to a medical condition or other health status related factor to satisfy the otherwise applicable standard; and
      2. (ii) a reasonable alternative standard, or waiver of the otherwise applicable standard, for obtaining the reward for any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard.
   2. (B) A plan or issuer may seek verification, such as a statement from an individual's physician, that medical condition or other health status related factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.
5. (5) The health benefit plan or policy, or health benefit plan or policy issuer, must disclose, in all plan materials describing the terms of the program, the availability of a reasonable alternative standard or the possibility of waiver of the otherwise applicable standard required under paragraph (4) of this section. However, if plan materials merely mention that a program is available, without describing its terms, this disclosure is not required.
6. (6) The following language, or substantially similar language, can be used to satisfy the requirement of paragraph (5) of this section: "If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under this program, call us at (insert telephone number) and we will work with you to develop another way to qualify for the reward."

Source Note:The provisions of this §21.4707 adopted to be effective March 31, 2009, 34 TexReg 2135.