2013 Maryland Code
INSURANCE
§ 15-509 - Incentive for bona fide wellness program [Effective until January 1, 2014]

§15-509.

(a) (1) In this section the following words have the meanings indicated.

(2) “Bona fide wellness program” means a program that is designed to:

(i) promote health or prevent or detect disease or illness;

(ii) reduce or avoid poor clinical outcomes;

(iii) prevent complications from medical conditions;

(iv) promote healthy behaviors; or

(v) prevent and control injury.

(3) “Carrier” means:

(i) an insurer;

(ii) a nonprofit health service plan;

(iii) a health maintenance organization; or

(iv) a dental plan organization.

(4) “Health factor” means, in relation to an individual, any of the following health status-related factors:

(i) health status;

(ii) medical condition;

(iii) claims experience;

(iv) receipt of health care;

(v) medical history;

(vi) evidence of insurability; or

(vii) disability.

(5) “Incentive” means:

(i) a discount of a premium or contribution;

(ii) a waiver of all or part of a cost-sharing mechanism, such as deductibles, copayments, or coinsurance;

(iii) the absence of a surcharge;

(iv) the value of a benefit that otherwise would not be provided under the policy or contract; or

(v) a rebate as permitted under § 27-210 of this article.

(b) (1) A carrier may provide reasonable incentives to an individual who is an insured, a subscriber, or a member for participation in a bona fide wellness program offered by the carrier if:

(i) the carrier does not make participation in the bona fide wellness program a condition of coverage under a policy or contract;

(ii) participation in the bona fide wellness program is voluntary and a penalty is not imposed on an insured, subscriber, or member for nonparticipation;

(iii) the carrier does not market the bona fide wellness program in a manner that reasonably could be construed to have as its primary purpose the provision of an incentive or inducement to purchase coverage from the carrier; and

(iv) the bona fide wellness program does not condition an incentive on an individual satisfying a standard that is related to a health factor.

(2) Notwithstanding paragraph (1)(iv) of this subsection, a carrier may condition an incentive for a bona fide wellness program on an individual satisfying a standard that is related to a health factor if:

(i) 1. all incentives for participation in the bona fide wellness program do not exceed 20% of the cost of employee-only coverage under the plan; or

2. when the plan provides coverage for family members, all incentives for participation in the bona fide wellness program do not exceed 20% of the cost of the coverage in which the family members are enrolled;

(ii) the bona fide wellness program is reasonably designed to promote health or prevent disease, as provided under subsection (c) of this section;

(iii) the bona fide wellness program gives individuals eligible for the bona fide wellness program the opportunity to qualify for the incentive under the bona fide wellness program at least once a year;

(iv) the bona fide wellness program is available to all similarly situated individuals; and

(v) individuals are provided a reasonable alternative standard or a waiver of the standard as required under subsection (d)(1) of this section.

(c) A bona fide wellness program shall be construed to be reasonably designed to promote health or prevent disease if the bona fide wellness program:

(1) has a reasonable chance of improving the health of or preventing disease in participating individuals;

(2) is not overly burdensome;

(3) is not a subterfuge for discriminating based on a health factor; and

(4) is not highly suspect in the method chosen to promote health or prevent disease.

(d) (1) A carrier shall provide a reasonable alternative standard, or a waiver of the otherwise applicable standard, for obtaining the incentive for any individual for whom it is:

(i) unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; or

(ii) medically inadvisable to attempt to satisfy the otherwise applicable standard.

(2) A carrier may seek verification, such as a statement from an individual’s health care provider, that a health factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.

(3) (i) A carrier shall disclose the availability of a reasonable alternative standard or a waiver of the otherwise applicable standard in all policy forms pertaining to the bona fide wellness program.

(ii) A carrier may meet the disclosure requirements of this paragraph by using the following language or substantially similar language:

“If it is unreasonably difficult due to a medical condition for you to achieve the standards for the incentive under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the incentive under this program, call us at (insert telephone number), and we will work with you to develop another way to qualify for the incentive.”.

(e) (1) In determining if a carrier’s bona fide wellness program meets the requirements of this section, the Commissioner may request a review of the bona fide wellness program by an independent review organization from the list compiled under § 15-10A-05(b) of this title.

(2) The expense of the review of the bona fide wellness program by an independent review organization shall be paid by the carrier, in the manner provided under § 15-10A-05(h) of this title.

§ 15-509 - Incentive for bona fide wellness program [Effective January 1, 2014]

(a) Definitions. --

(1) In this section the following words have the meanings indicated.

(2) "Bona fide wellness program" means a program that is designed to:

(i) promote health or prevent or detect disease or illness;

(ii) reduce or avoid poor clinical outcomes;

(iii) prevent complications from medical conditions;

(iv) promote healthy behaviors; or

(v) prevent and control injury.

(3) "Carrier" means:

(i) an insurer;

(ii) a nonprofit health service plan;

(iii) a health maintenance organization; or

(iv) a dental plan organization.

(4) "Health factor" means, in relation to an individual, any of the following health status-related factors:

(i) health status;

(ii) medical condition;

(iii) claims experience;

(iv) receipt of health care;

(v) medical history;

(vi) evidence of insurability; or

(vii) disability.

(5) "Incentive" means:

(i) a discount of a premium or contribution;

(ii) a waiver of all or part of a cost-sharing mechanism, such as deductibles, copayments, or coinsurance;

(iii) the absence of a surcharge;

(iv) the value of a benefit that otherwise would not be provided under the policy or contract; or

(v) a rebate as permitted under § 27-210 of this article.

(b) Conditions. --

(1) A carrier may provide reasonable incentives to an individual who is an insured, a subscriber, or a member for participation in a bona fide wellness program offered by the carrier if:

(i) the carrier does not make participation in the bona fide wellness program a condition of coverage under a policy or contract;

(ii) participation in the bona fide wellness program is voluntary and a penalty is not imposed on an insured, subscriber, or member for nonparticipation;

(iii) the carrier does not market the bona fide wellness program in a manner that reasonably could be construed to have as its primary purpose the provision of an incentive or inducement to purchase coverage from the carrier; and

(iv) the bona fide wellness program does not condition an incentive on an individual satisfying a standard that is related to a health factor.

(2) Notwithstanding paragraph (1)(iv) of this subsection, a carrier may condition an incentive for a bona fide wellness program on an individual satisfying a standard that is related to a health factor if:

(i) 1. all incentives for participation in the bona fide wellness program do not exceed 30% of the cost of employee-only coverage under the plan, except that the applicable percentage is increased by an additional 20 percentage points to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use; or

2. when the plan provides coverage for family members, all incentives for participation in the bona fide wellness program do not exceed 30% of the cost of the coverage in which the family members are enrolled, except that the applicable percentage is increased by an additional 20 percentage points to the extent that the additional percentage is in connection with a program designed to prevent or reduce tobacco use;

(ii) the bona fide wellness program is reasonably designed to promote health or prevent disease, as provided under subsection (c) of this section;

(iii) the bona fide wellness program gives individuals eligible for the bona fide wellness program the opportunity to qualify for the incentive under the bona fide wellness program at least once a year;

(iv) the bona fide wellness program is available to all similarly situated individuals; and

(v) individuals are provided a reasonable alternative standard or a waiver of the standard as required under subsection (d)(1) of this section.

(c) Reasonably designed to promote health or prevent disease. -- A bona fide wellness program shall be construed to be reasonably designed to promote health or prevent disease if the bona fide wellness program:

(1) has a reasonable chance of improving the health of or preventing disease in participating individuals;

(2) is not overly burdensome;

(3) is not a subterfuge for discriminating based on a health factor; and

(4) is not highly suspect in the method chosen to promote health or prevent disease.

(d) Reasonable alternative or waiver. --

(1) A carrier shall provide a reasonable alternative standard, or a waiver of the otherwise applicable standard, for obtaining the incentive for any individual for whom it is:

(i) unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; or

(ii) medically inadvisable to attempt to satisfy the otherwise applicable standard.

(2) A carrier may seek verification, such as a statement from an individual's health care provider, that a health factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.

(3) (i) A carrier shall disclose the availability of a reasonable alternative standard or a waiver of the otherwise applicable standard in all policy forms pertaining to the bona fide wellness program.

(ii) A carrier may meet the disclosure requirements of this paragraph by using the following language or substantially similar language:

"If it is unreasonably difficult due to a medical condition for you to achieve the standards for the incentive under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the incentive under this program, call us at (insert telephone number), and we will work with you to develop another way to qualify for the incentive.".

(e) Review. --

(1) In determining if a carrier's bona fide wellness program meets the requirements of this section, the Commissioner may request a review of the bona fide wellness program by an independent review organization from the list compiled under § 15-10A-05(b) of this title.

(2) The expense of the review of the bona fide wellness program by an independent review organization shall be paid by the carrier, in the manner provided under § 15-10A-05(h) of this title.