|
The health factors are:
The term evidence of insurability includes conditions arising out of
acts of domestic violence, as well as participation in activities such as
motorcycling, snowmobiling, all-terrain vehicle riding, horseback
riding, skiing, and other similar activities.
|
|
No. A group health plan or group health insurance issuer may not require
you to pass a physical examination for enrollment. Even if you are a late
enrollee, you may not be required to pass a physical examination in order to
be eligible for coverage.
|
|
No. The HIPAA nondiscrimination provisions do not
automatically prohibit health care questionnaires. It depends on how the
information that is obtained is used. In this case, the plan requires
individuals to score a certain number of Health Points that are
related to prior or current medical conditions in order to enroll in the
plan, which is impermissible discrimination in rules for eligibility based
on a health factor.
|
|
No. Participation in activities such as skiing is
evidence of insurability, a health factor. Therefore, you may not be denied
eligibility to enroll in your employer’s plan because you ski.
|
|
HIPAA sets forth specific limitations on a plan’s use
of preexisting condition exclusions. If a plan complies with these
limitations and applies the preexisting condition exclusion uniformly to all
similarly situated individuals and does not direct the exclusion at
individual participants and beneficiaries, the plan is considered to be in
compliance with the nondiscrimination provisions. (For a question and answer
discussing standards for defining similarly situated individuals, see below
under the heading Similarly Situated Individuals.)
For questions and answers that explain HIPAA’s limits
on preexisting condition exclusions, see the EBSA publication Questions
& Answers: Recent Changes in Health Care Law.
|
|
No. A group health plan may impose a preexisting
condition exclusion period, but the exclusion must be applied uniformly to
all similarly situated individuals. Here, the plan’s provisions do not
apply uniformly because individuals who have medical claims for the first
six months following enrollment are not treated the same as similarly
situated individuals with no claims during that period. Therefore, the plan
provision violates the HIPAA nondiscrimination provisions.
|
|
Group health plans may exclude coverage for a specific
disease, limit or exclude benefits for certain types of treatments or drugs,
or limit or exclude benefits based on a determination of whether the
benefits are experimental or medically necessary, if the benefit restriction
is applied uniformly to all similarly situated individuals and is not
directed at any individual participants or beneficiaries based on a health
factor. (Plan amendments applicable to all individuals in a group of
similarly situated individuals and made effective no earlier than the first
day of the next plan year after the amendment is adopted are not considered
to be directed at individual participants and beneficiaries.)
Therefore, as long as your plan’s condition-specific
benefit exclusion is applied uniformly to all similarly situated
individuals, and is not directed at individual participants or beneficiaries
based on a health factor, the benefit exclusion is permissible under the
HIPAA nondiscrimination provisions.
|
|
A group health plan may apply lifetime limits generally
or with respect to benefits for a specific disease or treatment, provided
the limits are applied uniformly to all similarly situated individuals and
are not directed at individual participants or beneficiaries based on a
health factor.
Therefore, both the $500,000 lifetime limit and the
$2,000 condition-specific lifetime limit are permissible if applied
uniformly to all similarly situated individuals and not directed at any
individual participants or beneficiaries based on a health factor.
|
|
If the injury results from a medical condition or an act
of domestic violence, the health plan or issuer may not deny benefits for
the injury, if it is an injury the plan would otherwise cover.
For example, a plan may not exclude coverage for
self-inflicted injuries (or injuries resulting from attempted suicide) with
respect to an individual if the injuries are otherwise covered by the plan
and if the individual’s injuries are the result of a medical condition,
such as depression.
However, a plan or issuer may exclude coverage for
injuries that do not result from a medical condition or domestic violence,
such as injuries sustained in high risk activities, such as bungee jumping.
(Nonetheless, as discussed above under the heading Prohibited
Discrimination in Rules for Eligibility, the plan could not exclude an
individual from enrollment for coverage because the individual participated
in bungee jumping.)
|
|
No. Group health plans and group health insurance issuers
cannot charge an individual more for coverage than a similarly situated
individual based on any health factor.
|
|
Yes. HIPAA does not restrict a health insurance issuer
from charging a higher rate to one group health plan (or employer) over
another. An issuer may take health factors of individuals into account when
establishing blended, aggregate rates for group health plans (or employers).
This may result in one health plan (or employer) being charged a higher
premium than another for the same coverage through the same issuer.
|
|
No. Issuers may not charge or quote an employer (or group
health plan) separate rates for individuals based on health factors. This
does not prevent issuers from taking the health factors of all individuals
into account in establishing a blended, aggregate rate for providing
coverage to the employment-based group overall. The issuer may then charge
the employer (or plan) a higher overall rate, or a higher, blended
per-participant rate. This prohibition against list-billing based on
health factors does not, however, restrict communications between issuers
and employers (or plans) regarding rate calculations.
|
|
Yes. The new rules provide that distinctions among groups
of similarly situated individuals may not be based on a health factor.
Instead, if distinguishing among participants, plans and issuers must base
distinctions on bona-fide employment based classifications consistent with
the employer’s usual business practice.
For example, part-time and full-time employees, employees
working in different geographic locations, and employees with different
dates of hire or lengths of service could be treated as distinct groups of
similarly situated individuals, provided the distinction is consistent with
the employer’s usual business practice. In addition, a plan or issuer
generally may treat participants and beneficiaries as two separate groups of
similarly situated individuals. The plan may also distinguish between
beneficiaries based, for example, on their relationship to the participant
(such as spouse or dependent child), or based on the age or student status
of dependent children.
Nonetheless, in any case, the creation or modification of
a classification cannot be directed at individual participants or
beneficiaries based on one or more of their health factors.
|
|
In January 2001, proposed regulations were issued with
respect to bona fide wellness programs and comments were invited. Until
further guidance is issued, the departments will not take any enforcement
action against a plan or issuer that complies with a good faith
interpretation of the statutory provisions relating to wellness program
provisions. Of course, compliance with the proposed regulations constitutes
good faith compliance with the statutory wellness programs provisions.
|
|
The requirements for bona fide wellness programs apply
only to a wellness program that provides a reward based on the ability of an
individual to meet a standard that is related to a health factor, such as a
reward conditioned on the outcome of a cholesterol test. Therefore, because
your wellness program does not base any reward on the outcome of the
testing, it is not subject to the requirements for bona fide wellness
programs.
|
|
The plan is offering a reward based on an individual’s
ability to stop smoking. Medical evidence seems to suggest that smoking may
be related to a health factor. (Under the Diagnostic and Statistical Manual
of Mental Disorders, nicotine addiction is a medical condition, and a report
of the Surgeon General stated that scientists in the field of drug addiction
agree that nicotine, a substance common to all forms of tobacco, is a
powerfully addictive drug.) Therefore, for the plan to maintain the premium
differential and not be considered to discriminate based on a health factor,
such a program would be required to meet the requirements for a bona fide
wellness program.
Under the proposed rules, there are four requirements to
be a bona fide wellness program:
-
The total reward that may be given to an individual
is limited. The departments invited comments on the appropriate level of
the reward, suggesting that a limit of 10-20 percent of the total cost
of employee-only coverage may be appropriate.
-
The program must be reasonably designed to promote
good health or prevent disease for individuals in the program.
-
The reward must be available to all similarly
situated individuals. More specifically, the program must allow any
individual for whom it is unreasonably difficult due to a medical
condition to meet the wellness program standard (or for whom it is
medically inadvisable to attempt to meet the wellness program standard)
an opportunity to satisfy a reasonable alternative standard.
-
All plan materials describing the terms of the
program must disclose the availability of a reasonable alternative
standard.
Accordingly, under the proposed rules, the wellness
program would be a bona fide wellness program if the premium differential is
not more than 10-20 percent of the total cost of employee-only coverage; the
program accommodates individuals for whom it is unreasonably difficult to
quit using tobacco products due to addiction by providing a reasonable
alternative standard (such as a discount in return for attending educational
classes or for trying a nicotine patch); and plan materials that describe
the premium differential describe the availability of a reasonable
alternative standard to qualify for the lower premium.
|
|
No. A group health plan may not restrict an
individual’s eligibility, benefits, or the effective date of coverage
based on the individual’s confinement in a hospital or other health care
facility. Additionally, a health plan may not set an individual’s premium
rate based on the individual’s confinement.
|
|
No. A group health plan or issuer generally may not
refuse to provide benefits because an individual is not actively at work on
the day the individual would otherwise become eligible for benefits.
However, these actively-at-work clauses are permitted if the plan treats
individuals who are absent from work due to a health factor (for example,
individuals taking sick leave) as if they are actively at work for purposes
of health coverage.
Nonetheless, a plan may require an individual to begin
work before coverage may become effective. Additionally, plans may
distinguish among groups of similarly situated individuals (for example, a
plan may require an individual to work full time, such as 250 hours per
quarter or 30 hours per week) in their eligibility provisions.
|
|
Yes. It is permissible for a plan or issuer to treat an
individual with an adverse health factor more favorably by offering extended
coverage.
|
|
HIPAA’s statutory provisions and the department’s
April 1997 regulations, including the nondiscrimination provisions,
generally were effective on the first day of the first plan year beginning
on or after July 1, 1997. In January 2001, the departments published more
comprehensive guidance on the nondiscrimination provisions. Portions of this
guidance that repeat the old regulations remain effective. Portions of the
regulations that provide new guidance are generally effective on the first
day of the first plan year beginning on or after July 1, 2001. If you have
questions as to which provisions are effective when, there is a helpful
chart in the preamble to the departments’ January 2001 regulations. For
more information, call the EBSA office nearest you, or see Nondiscrimination
in Health Coverage in the Group Market; Interim Final Rules and Proposed
Rules.
|
| |
|