Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter MM - WELLNESS PROGRAMS
Section 21.4707 - Activity-Only Wellness Programs
Universal Citation: 28 TX Admin Code § 21.4707
Current through Reg. 50, No. 13; March 28, 2025
(a) 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 an activity-only wellness program.
(b) An activity-only wellness program does not violate this subchapter so long as the requirements of this section are met.
(1) Size of reward. The reward for the
activity-only wellness program, coupled with the reward for other
health-contingent wellness programs offered under the same plan, must not
exceed in total value 30 percent of the cost of employee-only or member-only
coverage under the plan; or 50 percent of the cost of employee-only or
member-only coverage under the plan if the program includes a program designed
to prevent or reduce tobacco use, except that no more than 20 percent of the
reward may be attributable to the tobacco use program. However, if, in addition
to employees or members, any class of dependents--such as spouses or spouses
and dependent children--may participate in the activity-only wellness program,
the reward must not exceed 30 percent of the cost of the coverage in which an
employee or member, and any dependents, are enrolled; or 50 percent of the cost
of the coverage in which an employee or member, and any dependents, are
enrolled, to the extent that the additional 20 percent is in connection with a
program designed to prevent or reduce tobacco use.
(A) For purposes of this section, the cost of
coverage is determined based on the total amount of employer and employee
contributions toward the cost of coverage, or member contributions toward the
cost of coverage, for the benefit package under which the employee or member
is, or the employee or member and any dependents are, receiving
coverage.
(B) A reward can be in
the form of a discount or rebate of a premium or contribution; a waiver of all
or part of a cost-sharing mechanism such as deductibles, copayments, or
coinsurance; the absence of a surcharge; or the value of a benefit that would
otherwise not be provided under the plan.
(2) Reasonable design. The activity-only
wellness program must meet the criteria set out in §
21.4705 of this title. This
determination is based on all the relevant facts and circumstances.
(3) Frequency of opportunity to qualify. The
activity-only wellness program must give individuals eligible for the program
the opportunity to qualify for the reward under the program at least once per
year.
(4) Uniform availability and
reasonable alternative standards. The full reward under the activity-only
wellness program must be available to all similarly situated individuals.
(A) A reward under this section is available
to all similarly situated individuals for a period so long as the program
allows, at a minimum:
(i) a reasonable
alternative standard, or waiver of the otherwise applicable standard, for
obtaining the reward for any individual for whom, for that period, it is
unreasonably difficult due to a medical condition or other health
status-related factor to satisfy the otherwise applicable standard;
and
(ii) a reasonable alternative
standard, or waiver of the otherwise applicable standard, for obtaining the
reward for any individual for whom, for that period, it is medically
inadvisable to attempt to satisfy the otherwise applicable standard.
(B) To the extent that a
reasonable alternative standard under an activity-only wellness program is an
activity-only wellness program, it must comply with the requirements of this
subtitle in the same manner as if it were an initial program standard. To the
extent that a reasonable alternative standard under an activity-only wellness
program is an outcome-based wellness program, it must comply with the
requirements of §
21.4708 of this title.
(C) If reasonable under the circumstances, a
plan or issuer may seek verification, such as a statement from an individual's
personal physician, that the medical condition or other health status-related
factor makes it unreasonably difficult for the individual to satisfy or attempt
to satisfy the otherwise applicable standard of an activity-only wellness
program. Plans and issuers may seek verification with respect to requests for a
reasonable alternative standard for which it is reasonable to determine that
medical judgment is required to evaluate the validity of the request.
(5) Notice of availability of
reasonable alternative standard. The health benefit plan or policy, or health
benefit plan or policy issuer, must disclose, in all plan materials describing
the terms of an activity-only wellness program, the availability of a
reasonable alternative standard to qualify for the reward (and, if applicable,
the possibility of waiver of the otherwise applicable standard required under
paragraph (4) of this subsection), including contact information for obtaining
a reasonable alternative standard and a statement that recommendations from an
individual's personal physician will be accommodated. If plan materials merely
mention that an alternative program is available, without describing its terms,
this disclosure is not required.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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