[ Monday, September 19, 2005 ]


Non-AdSimp HIPAA: We forget that dealing with HIPAA is sort of like the parable of the blind men and the elephant: what you think HIPAA is depends on what part of HIPAA you regularly deal with. Around these parts, we mostly deal with privacy, security, and transaction and code sets. But there's a big part of HIPAA that's about portability (that is the "P" in HIPAA, of course), and there's also a part of HIPAA that deals with health insurance equity and non-discrimination. There's an obvious incentive for health insurers to only want to insure healthy people. But the concept of insurance is also about spreading the risk over as large a population as possible, so if you limit insurance pools to healthy people, those who really need it won't ever be able to get it. (As you can see, there's a tangent here to the portability requirements, too.) Employers are interested in this too, for multiple reasons: it reduces insurance costs (especially if they self-insure), and healthier employees miss less time at work, are more productive, are better adjusted mentally, smile brighter, smell better, etc.

There are provisions in Title I of HIPAA (administrative simplification is a subtitle of Title II) that restrict the ability of a health insurer to offer incentives to individuals who are healthier than others. An insurance plan can have a "bona fide wellness program" that encourages individuals to be healthier and provides them with a benefit for doing so (such as reduced insurance premiums if the individual enters a smoking cessassion program). But what if the individual can't or won't quit smoking? Should they be punished (or at least not rewarded) if he or she did his or her best, or should they all get trophies like a kids soccer team? Welcome to the 21st century.

For a bona fide wellness program to be bona fide, it must be either participation-based (just entering the program is sufficient; if it doesn't work for you, you get a trophy anyway) or, if it is outcomes based, it must meet 4 criteria: the reward is limited (an acceptable range is 10 - 20% premium savings); it is reasonably designed to promote good health and have at least annual open eligibility periods; it must be available to all and all must have opportunities to meet an alternative standard to receive the reward; and the plan must be clearly described, including the alternative standard part. The alternative standard is the gaping hole where all of the non-performing employees can get their trophy. But even with that, it's still a good idea for employers to encourage their employees to be healthy.

UPDATE: In response to a request via comment from George Taylor, the bona fide wellness regulations were printed in the Federal Register on January 8, 2001, as a part of the huge bulk of regulations regurgitated up by the Clinton Administration in its final pizza-flecked days. Yes, those same halcyon days that gave up the original HIPAA Privacy Regs, complete with required consents prior to any use or disclosure, regardless of whether the patient had a prior relationship with the provider. At any rate, the proposed regs, which do not appear to have been finalized, are at 66 Fed Reg 1421, and propose to add identical provisions to 26 CFR 54.9802-1(f) (IRC regulations); 29 CFR 2590.702(f) (ERISA regulations); and 45 CFR 146.121(f) (Public Health Service Act regulations).

Jeff [11:17 AM]

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