Texas amends wellness program regulations to reflect federal standards

The Texas Department of Insurance has adopted amendments to regulations concerning wellness programs. The amendments, which take effect on July 22, 2015, reflect updates adopted in federal regulations addressing wellness programs pursuant to the Patient Protection and Affordable Care Act.

Among other changes, the amendments:

• expand the scope of the provisions so that they also apply to individual or group accident and health insurance coverage, and to HMO coverage, rather than to small and large employer coverage only;

• clarify that a health-contingent wellness program that requires an individual to perform or complete an activity related to a health factor in order to obtain a reward but does not require the individual to attain or maintain a specific health outcome, is considered an “activity-only wellness program”;

• add references to, and allows awards for, health contingent wellness programs;

• increase maximum amount of awards under various types of programs, and for various types of participation;

• clarify certain provisions that apply specifically with respect to activity-only wellness programs;

• clarify the manner by which reasonable alternative standards will apply with respect to different types of programs;

• clarify the requirements and limitations that apply to insurer requests for provider verification regarding alternative standards;

• modify the requirements for notifications to insureds regarding the availability of alternative standards;

• specify that any health-contingent wellness program that requires an individual to attain or maintain a specific health outcome in order to obtain a reward, is considered an “outcome-based wellness program”;

• specify the manner by which outcome-based wellness program must be designed, the size and manner of awards, and the frequency by which individuals must be given the opportunity to qualify; and

• add provisions addressing alternative standards.

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