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They are:=20
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health status; =
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medical condition, =
including both=20
physical and mental illnesses;
-
claims =
experience;
-
receipt of health =
care;
-
medical history; =
-
genetic =
information;
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evidence of =
insurability; and=20
-
disability. =
The term =93evidence of insurability=94 =
includes=20
conditions arising from acts of domestic violence, as well =
as=20
participation in activities such as motorcycling, =
snowmobiling,=20
all-terrain vehicle riding, horseback riding, skiing, and =
other=20
similar activities.=20
No. A group health =
plan=20
may not require an individual to pass a physical exam for=20
enrollment, even if the individual is a late enrollee.=20
Yes, provided that the health information =
is not=20
used to deny, restrict, or delay eligibility or benefits, or =
to=20
determine individual premiums.=20
Group=20
health plans may exclude coverage for a specific disease, =
limit or=20
exclude benefits for certain types of treatments or drugs, =
or limit=20
or exclude benefits based on a determination that the =
benefits are=20
experimental or medically unnecessary - but only if the =
benefit=20
restriction applies uniformly to all similarly situated =
individuals=20
and is not directed at individual participants or =
beneficiaries=20
based on a health factor they may have. (Plan amendments =
that apply=20
to all individuals in a group of similarly situated =
individuals and=20
that are effective no earlier than the first day of the next =
plan=20
year after the amendment is adopted are not considered to be =
directed at individual participants and beneficiaries.)=20
Compliance with HIPAA=92s =
nondiscrimination=20
provisions does not in any way reflect compliance with any =
other=20
provision of ERISA (including COBRA and ERISA=92s fiduciary=20
provisions). Nor does it reflect compliance with other State =
or=20
Federal laws (such as the Americans with Disabilities Act).=20
If the injury results from =
a=20
medical condition or an act of domestic violence, a plan may =
not=20
deny benefits for the injury - if it is an injury the plan =
would=20
otherwise cover.=20
For example, a plan may not exclude =
coverage for=20
self-inflicted injuries (or injuries resulted from attempted =
suicide) if the individual=92s injuries are otherwise =
covered by the=20
plan and if the injuries are the result of a medical =
condition (such=20
as depression).=20
However, a plan may exclude coverage for =
injuries=20
that do not result from a medical condition or domestic =
violence,=20
such as injuries sustained in high risk activities (for =
example,=20
bungee jumping). But the plan could not exclude an =
individual from=20
enrollment for coverage because the individual participated =
in=20
bungee jumping.=20
No. =
Group=20
health plans cannot charge an individual more for coverage =
than=20
other similarly situated individuals based on any health =
factor.=20
Distinctions =
among groups=20
of similarly situated participants in a health plan must be =
based on=20
bona-fide employment-based classifications consistent with =
the=20
employer=92s usual business practice. Distinctions cannot be =
based on=20
any of the health factors noted earlier.=20
For example, part-time and full-time =
employees,=20
employees working in different geographic locations, and =
employees=20
with different dates of hire or lengths of service can be =
treated as=20
distinct groups of similarly situated individuals, with =
different=20
eligibility provisions, different benefit restrictions, or =
different=20
costs, provided the distinction is consistent with the =
employer=92s=20
usual business practice.=20
In addition, a plan generally may treat=20
participants and beneficiaries as two separate groups of =
similarly=20
situated participants. The plan also may distinguish between =
beneficiaries based on, for example, their relationship to =
the plan=20
participant (such as spouse or dependent child) or based on =
the age=20
or student status of dependent children.=20
In any case, a plan cannot create or =
modify a=20
classification directed at individual participants or =
beneficiaries=20
based on one or more of the health factors.=20
Yes. In=20
fact, HIPAA does not restrict a health insurance issuer from =
charging a higher rate to one group health plan (or =
employer) over=20
another. An issuer may take health factors of individuals =
into=20
account when establishing blended, aggregate rates for group =
health=20
plans (or employers). This may result in one health plan (or =
employer) being charged a higher premium than another for =
the same=20
coverage through the same issuer.=20
No. Issuers may not charge or quote =
an=20
employer or group health plan separate rates that vary for=20
individuals (commonly referred to as =93list billing=94), =
based on any=20
of the health factors.=20
This does not prevent issuers from taking =
the=20
health factors of each individual into account when =
establishing a=20
blended, aggregate rate for providing coverage to the=20
employment-based group overall. The issuer may then charge =
the=20
employer (or plan) a higher overall rate, or a higher =
blended=20
per-participant rate.=20
While HIPAA prohibits list billing based =
on health=20
factors, it does not restrict communications between issuers =
and=20
employers (or plans) regarding the factors considered in the =
rate=20
calculations.=20
No. A group =
health plan=20
may not deny or delay an individual=92s eligibility, =
benefits, or the=20
effective date of coverage because that individual is =
confined to a=20
hospital or other health care facility. In addition, a =
health plan=20
may not set an individual=92s premium rate based on that =
person=92s=20
confinement.=20
No. Generally a group health plan may not =
refuse to=20
provide benefits because an individual is not actively at =
work on=20
the day that individual would otherwise become eligible for=20
benefits. However, plans may have actively-at-work clauses =
if the=20
plan treats individuals who are absent from work due to a =
health=20
factor (for example, individuals taking sick leave) as if =
they are=20
actively at work for purposes of health coverage.=20
Plans may require individuals to report =
for the=20
first day of work before coverage may become effective. In =
addition,=20
plans may distinguish among groups of similarly situated =
individuals=20
in their eligibility provisions. For example, a plan may =
require an=20
individual to work full time, such as 250 hours per quarter =
or 30=20
hours per week to be eligible for health plan coverage.=20
Yes, a plan can treat an individual =
with an=20
adverse health factor more favorably by offering extended =
coverage.=20
The HIPAA =
nondiscrimination provisions generally prohibit group health =
plans=20
from charging similarly situated individuals different =
premiums or=20
contributions or imposing different deductible, copayment or =
other=20
cost sharing requirements based on a health factor. However, =
there=20
is an exception that allows plans to offer wellness =
programs.=20
If none of the conditions for obtaining a =
reward=20
under a wellness program are based on an individual =
satisfying a=20
standard related to health factor, or if no reward is =
offered, the=20
program complies with the nondiscrimination requirements =
(assuming=20
participation in the program is made available to all =
similarly=20
situated individuals). For example:=20
-
A program that =
reimburses all or=20
part of the cost for memberships in a fitness =
center.
-
A diagnostic testing =
program that=20
provides a reward for participation rather than =
outcomes.=20
-
A program that =
encourages preventive=20
care by waiving the copayment or deductible requirement =
for the=20
costs of, for example, prenatal care or well-baby =
visits.=20
-
A program that =
reimburses employees=20
for the costs of smoking cessation programs without regard =
to=20
whether the employee quits smoking.
-
A program that provides =
a reward to=20
employees for attending a monthly health education =
seminar.=20
Wellness programs that condition a reward =
on an=20
individual satisfying a standard related to a health factor =
must=20
meet five requirements described in the final rules in order =
to=20
comply with the nondiscrimination rules.=20
The wellness program rules are generally =
effective=20
for the plan year starting on or after July 1, 2007.=20
=20
-
The total reward for all =
the plan=92s=20
wellness programs that require satisfaction of a standard =
related=20
to a health factor is limited =96 generally, it must not =
exceed 20=20
percent of the cost of employee-only coverage under the =
plan. If=20
dependents (such as spouses and/or dependent children) may =
participate in the wellness program, the reward must not =
exceed 20=20
percent of the cost of the coverage in which an employee =
and any=20
dependents are enrolled.
-
The program must be =
reasonably=20
designed to promote health and prevent disease. =
-
The program must give =
individuals=20
eligible to participate the opportunity to qualify for the =
reward=20
at least once per year.
-
The reward must be =
available to all=20
similarly situated individuals. The program must allow a=20
reasonable alternative standard (or waiver of initial =
standard)=20
for obtaining the reward to any individual for whom it is=20
unreasonably difficult due to a medical condition, or =
medically=20
inadvisable, to satisfy the initial standard.
-
The plan must disclose =
in all=20
materials describing the terms of the program the =
availability of=20
a reasonable alternative standard (or the possibility of a =
waiver=20
of the initial standard).
The plan=92s program does =
not base any=20
reward on the outcome of the testing. Thus, it is allowed =
under the=20
HIPAA nondiscrimination provisions without being subject to =
the five=20
requirements for wellness programs that do require =
satisfaction of a=20
standard related to a health factor.=20
The =
plan is=20
offering a reward based on an individual=92s ability to stop =
smoking.=20
Medical evidence suggests that smoking =
may be=20
related to a health factor. The Diagnostic and =
Statistical Manual=20
of Mental Disorders, which states that nicotine =
addiction is a=20
medical condition, supports that position. In addition, a =
report of=20
the Surgeon General adds that scientists in the field of =
drug=20
addiction agree that nicotine, a substance common to all =
forms of=20
tobacco, is a powerfully addictive drug.=20
For a group health plan to maintain a =
premium=20
differential between smokers and nonsmokers and not be =
considered=20
discriminatory, the plan=92s nonsmoking program would need =
to meet the=20
five requirements for wellness programs that require =
satisfaction of=20
a standard related to a health factor.=20
Accordingly, under the final rules, this =
wellness=20
program would be permitted if:=20
-
The premium differential =
is not more=20
than 20 percent of the total cost of employee-only =
coverage (or=20
20% of the cost of coverage if dependents can participate =
in the=20
program);
-
The program is =
reasonably designed=20
to promote health and prevent disease;
-
Individuals eligible for =
the program=20
are given an opportunity to qualify for the discount at =
least once=20
per year;
-
The program accommodates =
individuals=20
for whom it is unreasonably difficult to quit using =
tobacco=20
products due to addiction by providing a reasonable =
alternative=20
standard (such as a discount in return for attending =
educational=20
classes or for trying a nicotine patch); and
-
Plan materials =
describing the terms=20
of the premium differential describe the availability of a =
reasonable alternative standard to qualify for the lower=20
premium. =