What Types of Wellness Programs are Exempt from HIPAA?

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HIPAA's non-discrimination requirements extend to all wellness plans that are "based on a health factor". Did you know that there is an exemption for other types of wellness plans? It's true. Wellness programs which are "participation only" programs need not be concerned with HIPPA.

A wellness plan qualifies as a "participation only" plan if it does not condition eligibility for a reward on a participant's ability to meet a health standard. Make sense? Well, here are some examples and rules that may help with understanding the concept of a "participation only" wellness plan. 

In these examples, participants earn the reward merely through participation, not meeting a health standard. When designing your program, keep in mind that the program must be available to all similarly-situated employees.

  • Incentives to participate in a health fair
  • Incentives for testing, or health risk assessments
  • Waiver of copays or deductibles for preventive screenings
  • Reimbursement of health club memberships
  • Reimbursement for smoking cessation or weight loss programs, regardless of outcome, since the reward cannot be tied to meeting a health standard.

Is Your Wellness Program Subject to HIPAA?

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Here is the short answer.  If receiving a reward or avoiding a penalty is tied to satisfaction of a standard that is related to a health factor, then the wellness plan must comply with HIPAA’s wellness regulations.

So, what does “related to a health factor” mean?  A health factor means the health status factors identified by HIPAA regulations. These “health factors” include “health status,” “medical condition” and “medical history.”  According to our legal consultant (who I enjoy referring to as "my lawyer friend"), the terms are meant to be overlapping “and, in combination, include any factor related to an individual’s health.” 

Wow, any factor. That includes quite a bit, so I started thinking of the possibilities. What if the person were an alcoholic, or maybe a cocaine or other illegal drug user?  My lawyer friend couldn’t find any specific guidance stating that the term “health factor” would not include a health factor related to an illegal act (for example, the health factor of being addicted to cocaine, due to illegal use of cocaine).  This means that use of illegal drugs is a health factor, and if receiving a wellness reward or avoiding a penalty is tied to NOT being a user of illegal drugs, then the wellness program is subject to HIPAA.