Final Wellness Regulations: What You Need to Know LIVE Webcast

Speaker Firms and Organization:

Alyson MathewsPartner

Lamb & Barnosky, LLP

Kendra RobersonOf Counsel

Covington & Burling LLP

Joseph F. ConiglioShareholder

Greenberg Traurig, LLP

Magan Pritam RayShareholder

Greenberg Traurig, LLP

Jim PshockFounder and Chief Executive Officer

Bravo Wellness

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Presented By:

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Partner Firms:

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Partner Firms:

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Lamb & Barnosky, LLP is one of Long Island's largest and most respected law firms, representing a wide variety of corporate, municipal and individual

clients. As a full-service law firm, Lamb & Barnosky, LLP is comprised of numerous practice areas, including Banking; Real Estate; Taxation;

Corporate Mergers and Acquisitions; Education; Labor and Employment; Municipal; Health Care; Intellectual Property, Land Use, Planning,

Environmental and Zoning; and Trusts and Estates.

The firm has an AV rating from Martindale-Hubbell, the nationally renowned legal directory, recognizing the firm's commitment to providing the highest standard of legal ability, professional conduct and ethics. Additionally, the firm has been named to the Bar Register of Preeminent Lawyers. The firm

proudly honors its commitment to pro bono and bar association work by having several partners who have served/currently serve on New York State

and local bar association boards.

Covington & Burling LLP, a full-service firm with over 850 lawyers in Beijing, Brussels, London, New York, San Diego, San Francisco, Seoul, Shanghai,

Silicon Valley, and Washington, is one of the leading international life sciences law firms in the world. Covington represents most of the major biotechnology and pharmaceutical companies in the United States and

Europe and numerous other life sciences companies worldwide. Covington also advises and represents hospitals, health plans, and other health care

providers on issues involving payment and reimbursement under a range of federal and state health care programs and on issues of health information

privacy. With its multi-disciplinary and multi-jurisdictional practice that integrates regulatory, corporate, transactional, intellectual property, litigation, competition, and trade law expertise, Covington meets the specialized needs

of life sciences and health care companies.

Partner Firms:

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Greenberg Traurig, LLP is an international, multi-practice law firm with approximately 1750 attorneys serving clients from 36 offices in the United

States, Latin America, Europe, the Middle East and Asia. Greenberg Traurig is among the Top 10 law firms on The National Law Journal's 2013 NLJ 350,

an annual ranking of the largest firms in the U.S.

GT provides integrated legal services for clients worldwide. The firm offers a multidisciplinary team, including senior lawyers who have been the chief

legal officers at major multinational companies and have spent years solving real-world problems in the business, political and legal environments of

major commercial centers. GT’s experience in more than 100 practice areas and their network of contacts throughout the world positions them to help

clients achieve their objectives both domestically and in the global marketplace.

Founded in 2008, Bravo Wellness is the thought leader in health-contingent wellness incentive programs. Bravo's market leadership provides unique insights into industry best practices, identifies ways to mitigate the cost of

healthcare, and minimize potential legal risks or compliance concerns. Bravo helps employers engage their employees, foster personal accountability, and bring about real behavior change towards better health and wellness. Bravo

Wellness and its subsidiary, IncentiSoft Solutions, are headquartered in Cleveland, OH. For more information, visit www.bravowell.com.

Brief Speaker Bios:

Alyson Mathews

Alyson Mathews represents employers in labor and employment law matters. She has assisted clients with grievance arbitrations, improper practice charges before PERB, disciplinary charges and contract negotiations. Ms. Mathews has comprehensive knowledge of the Affordable Care Act, including employer implementation strategies and best personnel practices. She has been featured in the Long Island Business News' Who's Who in Women in Professional Services.

January 30, 2014

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Kendra Roberson

Kendra Roberson, of counsel at Covington & Burling LLP, advises clients on a broad spectrum of employee benefits matters, including tax-qualified retirement plans, employee stock ownership plans, executive compensation arrangements, stock option and other equity-based compensation plans, cafeteria plans, VEBAs, self-insured medical plans, and other health and welfare plans. Her experience includes plan design and drafting, regulatory compliance, ERISA litigation, and handling employee benefits matters and plans in corporate transactions. In addition, Ms. Roberson has extensive experience advising employers and state governments on compliance with the Patient Protection and Affordable Care Act ("PPACA")

Brief Speaker Bios:

Joseph F. Coniglio

Joseph F. Coniglio has wide-ranging experience in the areas of health care law and complex business litigation. He represents hospitals, physicians, and other related health care entities in litigation and transactional matters. He also provides service on a national basis to privately held and publicly traded companies related to corporate entity issues and health care regulatory matters. Joe advises health care clients on operational matters, liability exposure of corporate entities, federal and state health care regulatory compliance involving complex fraud issues and health care reimbursement disputes, as well as professional liability and risk management. He also represents health care providers before their respective state boards in grievance and disciplinary proceedings. Joe received his J.D., cum laude, from Texas Tech University School of Law.

January 30, 2014

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Magan Pritam Ray

Magan Pritam Ray has wide-ranging experience in all facets of employee benefits, compensation and ERISA matters, including the design, implementation and operation of retirement plans, health and welfare benefit plans, cafeteria plans, fringe benefit plans, and non-qualified deferred compensation programs. Magan is a specialist in counseling clients on the business impact, strategic response, plan design and compliance with health care reform. Magan regularly advises clients, from startups to Fortune 100 companies, on issues in mergers, acquisitions, spin-offs and joint ventures. Magan also has experience in representing companies undergoing employee benefits, employment and tax audits before the IRS, DOL and EDD. She received her J.D., with distinction, from Stanford Law School.

Brief Speaker Bios:

Jim Pshock

Jim Pshock is a leader known for cutting-edge innovation in the healthcare sector. His career spans over 20 years in the health insurance industry including executive positions in technology, operations, sales, marketing and corporate strategy with carriers and third-party administrators. Jim has developed a comprehensive and unique expertise in the regulations related to governing wellness programs and the practical application of incentives to improve employee health.

Jim frequently presents to regional and national audiences, including human resource professionals, occupational health professionals and insurance industry associations. He also serves on a national committee of HERO, an advocacy group exploring the innovation and evaluation of worksite wellness. Jim was recognized for his talents receiving the Northeast Ohio Ernst & Young Entrepreneur of the Year® Award in 2011.

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► For more information about the speakers, you can visit: http://www.knowledgecongress.org/speakers_2014_Final_Wellness.html

Recently, the Department of Health and Human Services (DHHS) issued final wellness regulations governing health- out-come-based wellness programs increasing rewards to up to 50 percent for healthy activity such as smoking cessation. The new regulations were published on June 3, 2013 and become effective on January 1, 2014 (or upon renewal after January 1, 2014). As compliance date draws near, companies should have a complete and thorough understanding of the final rules to avoid potentially steep penalties.

The Knowledge Group has assembled a panel of key thought leaders and practitioners to provide the audience with an in-depth analysis of the Final Wellness Regulations. In a two-hour live webcast, speakers will discuss:

- Recent Developments and Key Changes on Final Wellness Regulations- Enforcement of and Compliance with the Final Rules- Impact of the Final Rules- Penalties and Exemptions- Best Practices in Compliance- Up to the Minute Regulatory Changes

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Featured Speakers:

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SEGMENT 1:

Alyson MathewsPartnerLamb & Barnosky, LLP

SEGMENT 2:

Kendra RobersonOf CounselCovington & Burling LLP

SEGMENT 3:

Joseph F. ConiglioShareholderGreenberg Traurig, LLP

SEGMENT 3:

Magan Pritam RayShareholderGreenberg Traurig, LLP

SEGMENT 4:

Jim PshockFounder and Chief Executive OfficerBravo Wellness

Introduction

Alyson Mathews represents employers in labor and employment law matters. She has assisted clients with grievance

arbitrations, improper practice charges before PERB, disciplinary charges and contract negotiations. Ms. Mathews has

comprehensive knowledge of the Affordable Care Act, including employer implementation strategies and best personnel

practices. She has been featured in the Long Island Business News' Who's Who in Women in Professional Services.

Ms. Mathews is actively involved in the NYSBA and serves on the Electronic Communications Committee and on the

Executive Committee of the Labor and Employment Law Section. She is a co-editor of NYSBA's second edition of Impasse

Resolution under the Taylor Law. Ms. Mathew is also a member of the American Bar Association and the Suffolk County

Bar Association.

Ms. Mathews received her law degree from Brooklyn Law School and her undergraduate degree, cum laude, from Boston

College.

January 30, 2014

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SEGMENT 1:


Overview of Wellness Programs

• Program Goals:– Promote health and prevent disease– Keep healthy individuals healthy – Encourage unhealthy individuals to change their behavior to reduce or eliminate risk factors

• Incentives (“Carrot & Stick Approach”)– Carrot Reward

• Reduction in premium costs• Waiver of copays or deductibles

– Stick Penalty• Surcharge

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SEGMENT 1:


HIPAA Non-Discrimination Rules

• The Health Insurance Portability and Accountability Act (HIPAA) prohibits a group health plan from discriminating against similarly situated participants based upon health status.

• A wellness program is not a group health plan if, in general, the program is offered to all employees regardless of whether they are enrolled in the employer’s health plan and the program does not provide any medical care.

– Example: A wellness program that provides employees with a discounted gym membership is not a group health plan.

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SEGMENT 1:


HIPAA Non-Discrimination Rules

• Providing medical care may include:– Health assessments– Screenings– Immunizations

• In addition, a wellness program becomes a group health plan if it provides rewards or penalties with regard to premiums.

• The final wellness program regulations, as amended by the Affordable Care Act, set forth the requirements for wellness programs to comply with the HIPAA non-discrimination rules.

– Regulations apply to any group health plan (grandfathered or nongrandfathered) and group health insurance issuers offering coverage for plan years beginning on or after January 1, 2014

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SEGMENT 1:


Two Types of Wellness Programs

• Participatory– Eligibility for reward is unrelated to a health factor; or– No reward offered– Must be available to all “similarly situated individuals,” regardless of health status

• Health-Contingent– Must satisfy a standard related to a health factor in order to obtain a reward; or– Must do more than a similarly situated individual based on a health factor to obtain the same

reward

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SEGMENT 1:


Examples of Participatory Wellness Programs thatAre Unrelated to a Health Factor

• Reimburse employees for all or part of cost for gym membership• Reward for participation in diagnostic testing program (without regard to outcome)• Encourage preventive care by waiving copay or deductible• Reimbursement for participating in smoking cessation program (without regard to whether employee

quits)• Reward for attending a monthly, no-cost health education seminar• Reward for completing health risk assessment regarding current health status

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SEGMENT 1:


Two Types of Health-Contingent Wellness Programs

• Activity-Only– Requires individual to perform or complete an activity that is related to a health factor in order to

obtain a reward, but does not require a specific outcome• Examples: Diet or exercise program

• Outcome-Based– Requires individual to attain or maintain a specific health outcome in order to obtain a reward or

avoid a penalty• Examples: Attain/maintain healthy BMI or cholesterol level

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SEGMENT 1:


Requirements for Health Contingent Programs

Generally, the same requirements apply to activity-only and outcome-based wellness programs.•Frequency: Must be able to qualify for full reward at least once per year•Size of Reward: up to 30% of total cost of employee coverage, or up to 50% if additional percentage is in connection with a program designed to prevent or reduce tobacco use

– If spouses and dependents can participate in the wellness program, then the size of the reward is based on the total cost of the coverage in which they are enrolled.

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SEGMENT 1:



• Reasonable Design: – Must have reasonable chance of improving the health of, or preventing disease in, participating

individuals– Must not be overly burdensome– Must not be a subterfuge for discriminating based upon a health factor– Must not be highly suspect in the method chosen to promote health or prevent disease

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SEGMENT 1:



• Uniform Availability and Reasonable Alternative Standards: must be available to all similarly situated individuals

– Achieved by providing reasonable alternative standard (or waiver of otherwise applicable standard)

– Differences between activity-only and outcome-based wellness programs

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SEGMENT 1:



• Notice of Availability of Reasonable Alternative Standard: – All plan materials describing the terms of the wellness program must disclose the availability of

a reasonable alternative standard (or the possibility of a waiver)– Must include contact information for obtaining a reasonable alternative standard– Must include a statement that the recommendations of an individual’s personal physician will be

accommodated– For outcome-based programs, must also include the availability of a reasonable alternative

standard in any disclosure that an individual did not satisfy the initial outcome-based standard

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SEGMENT 1:


Uniform Availability & Reasonable Alternative StandardActivity-Only Wellness Programs

• Plan must provide a reasonable alternative standard for obtaining the reward (or waiver of otherwise applicable standard) for any individual for whom, for that period, it is:

– Unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; or– Medically inadvisable to attempt to satisfy the otherwise applicable standard

• No obligation to determine a reasonable alternative standard in advance, but one must be furnished upon request or the condition for obtaining the reward must be waived.

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SEGMENT 1:



• All facts and circumstances are taken into account to determine whether the plan offered a reasonable alternative standard including, but not limited to:

– If the reasonable alternative standard is an educational program, the program is made available by the plan (or assistance is given for finding one) and is free of charge.

– If the reasonable alternative standard is a diet program, the plan must pay for the membership or participation fee, but not the cost of food.

– Whether required time commitment is reasonable– If individual’s personal physician states that a plan standard is not medically appropriate, plan

must provide a reasonable alternative standard that accommodates the physician’s recommendations.

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SEGMENT 1:



• A reasonable alternative standard may be participatory, activity-only or outcome-based– If participatory, the individual is eligible for the reward so long as he/she participates. No

additional reasonable alternative standard must be provided if the individual elects not to participate.

– If activity-only, a second reasonable alternative standard must be provided if the first reasonable alternative standard was unreasonably difficult to complete due to a medical condition or medically inadvisable to attempt to complete.

– If outcome-based, must satisfy rules for outcome-based programs

January 30, 2014

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SEGMENT 1:


Uniform Availability & Reasonable Alternative StandardOutcome-Based Wellness Programs

• Plan must provide reasonable alternative standard (or waiver of otherwise applicable standard) for any individual who does not meet the initial standard based on the measurement, test or screening

– Does not matter whether initial standard was unreasonably difficult– Does not matter whether initial standard was medically inadvisable to attempt to achieve– Cannot require physician verification that a health factor makes it unreasonably difficult to

satisfy or medically inadvisable for the individual to attempt to satisfy the otherwise applicable standard as a condition of providing a reasonable alternative standard

• Whether plan furnished a reasonable alternative standard depends on the facts and circumstances (same rules as for activity-only)

January 30, 2014

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SEGMENT 1:



• A reasonable alternative standard may be participatory, activity-only or outcome-based– If participatory, the individual is eligible for the reward so long as he/she participates. No

additional reasonable alternative standard must be provided if the individual elects not to participate.

– If activity-only, then a second reasonable alternative standard must be provided if the first reasonable alternative standard was unreasonably difficult to complete due to a medical condition or medically inadvisable to attempt to complete.

– If outcome-based, must satisfy rules for outcome-based programs, subject to additional special rules.

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SEGMENT 1:



• Special Rules– Reasonable alternative standard cannot be a requirement to meet a different level of the same

standard without additional time to comply that takes into account the individual’s circumstances.

• Example: If the initial standard is achieving a BMI of less than 30, the reasonable alternative standard cannot be to achieve a BMI of less than 31 as of the same deadline. A permissible reasonable alternative standard could be to reduce the individual’s BMI by a small percentage over a realistic period of time, such as one year.

– Individual must be given the opportunity to comply with the recommendations of his/her personal physician as a second reasonable alternative standard, but only if the physician joins in the request. The individual may request to involve his/her personal physician’s recommendations at any time, and the personal physician can adjust his/her recommendations at any time, “consistent with medical appropriateness.”

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SEGMENT 1:


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SEGMENT 1:


Alyson Mathews, Esq.534 Broadhollow Road - Suite 210

P.O. Box 9034Melville, New York 11747

[email protected]

lambbarnosky.com

Trust, Personal Attention and Results®

Introduction

Kendra Roberson, of counsel at Covington & Burling LLP, advises clients on a broad spectrum of employee benefits

matters, including tax-qualified retirement plans, employee stock ownership plans, executive compensation arrangements,

stock option and other equity-based compensation plans, cafeteria plans, VEBAs, self-insured medical plans, and other

health and welfare plans. Her experience includes plan design and drafting, regulatory compliance, ERISA litigation, and

handling employee benefits matters and plans in corporate transactions. In addition, Ms. Roberson has extensive

experience advising employers and state governments on compliance with the Patient Protection and Affordable Care Act

("PPACA")

January 30, 2014

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SEGMENT 2:


Disclaimer

This presentation provides general information, not legal advice as to any specific matter. It should not be used as a substitute for appropriate legal advice.

January 30, 2014

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SEGMENT 2:


Americans with Disabilities Act (ADA): Application to Benefits

• Prohibits providing benefits on a less favorable basis because of a disability– however, disability-based distinctions permissible if not a “subterfuge” to evade ADA– subterfuge if not justified by risks or costs

January 30, 2014

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SEGMENT 2:


ADA: Application to Employers

• Requires reasonable accommodation to enable disabled to participate in wellness program• Limits employer’s ability to make disability-related inquiries or require medical exams

– E.g., cholesterol screenings, health risk assessments – EEOC has said permissible if “voluntary”

January 30, 2014

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SEGMENT 2:


ADA: Voluntary Inquiries/Exams

• Meaning of voluntary unclear based on EEOC guidance:– clearly “involuntary” to condition health coverage on completion of HRA– “Could be involuntary” to provide financial incentive – threshold amount unknown.

January 30, 2014

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SEGMENT 2:


ADA: Voluntary Inquiries/Exams

• Seff v. Broward County, 691 F.3d 1221 (11th Cir. 2012)– a wellness program that is part of a bona fide group health plan might not violate ADA even if

“involuntary”– must not be a subterfuge for evading ADA– must have an underwriting purpose

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SEGMENT 2:


ADA: Key Questions

• Is there a disability-related inquiry or medical examination?• Is there a financial incentive?• Is reasonable accommodation provided?

January 30, 2014

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SEGMENT 2:


ADA: Examples

• Reward for completing medical questionnaire about family medical history:– genetic information = disability-related inquiry (ADA applies)– Generally not permitted unless voluntary– Incentive might make involuntary

• Reward for walking 3 miles per week (activity-only program)– Must provide reasonable accommodation– May require documentation that accommodation necessary

January 30, 2014

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SEGMENT 2:


GINA and Health Risk Assessments

• Genetic information– genetic test (individual and family members)– family medical history (manifestation of disease/disorder)– genetic services/information (individual, family, fetus, embryo)

January 30, 2014

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SEGMENT 2:



• Title I: Prohibits plans from requesting, requiring, or purchasing GI – prior to or in connection with enrollment

• date coverage is effective– for purposes of underwriting

• includes financial incentive for providing GI, including family history• cannot use voluntarily provided GI to guide employee to a wellness program

January 30, 2014

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SEGMENT 2:



• Title II: prohibits employer from requesting, requiring, or purchasing genetic information about job applicant or employee

– exception for voluntary wellness programs– information can be used to guide employees and provide financial incentives to participate in

wellness programs

January 30, 2014

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SEGMENT 2:



• Employer has three options– Do not offer financial incentive to complete HRA– Offer incentive but do not include questions concerning family medical history (and state that

should not volunteer family medical history)– Offer incentive only for completing questions that do not relate to family medical history (and

identify questions)

January 30, 2014

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SEGMENT 2:


GINA: Key Questions

• Is the request made by employer or health plan? – If health plan, is request made prior to enrollment?

• Is there a financial incentive?• Is genetic information sought?

January 30, 2014

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SEGMENT 2:


GINA: Examples

• Reward for completing medical questionnaire about family medical history:– family medical history = genetic information (GINA applies)– No incentive is permitted by employer/plan– If no incentive, employer could use to guide to wellness program; plan could not give before

enrollment or use to guide to wellness programs• Reward for walking 3 miles per week (activity-only program)

– GINA does not apply

January 30, 2014

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SEGMENT 2:


ADA and GINA Enforcement

• ADA and Title II GINA: EEOC or employee lawsuit seeking compensatory and punitive damages• Title I GINA: Excise taxes under IRC, agency enforcement actions, and private lawsuits under

ERISA

January 30, 2014

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SEGMENT 2:


Questions?

Kendra Roberson(202) 662-5044

[email protected]

January 30, 2014

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SEGMENT 2:


February 11, 2014

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Introduction

Joseph F. Coniglio has wide-ranging experience in the areas of health care law and complex business litigation. He

represents hospitals, physicians, and other related health care entities in litigation and transactional matters. He also

provides service on a national basis to privately held and publicly traded companies related to corporate entity issues and

health care regulatory matters. Joe advises health care clients on operational matters, liability exposure of corporate

entities, federal and state health care regulatory compliance involving complex fraud issues and health care reimbursement

disputes, as well as professional liability and risk management. He also represents health care providers before their

respective state boards in grievance and disciplinary proceedings. Joe received his J.D., cum laude, from Texas Tech

University School of Law.

January 30, 2014

49

SEGMENT 3:


Introduction

Magan Pritam Ray has wide-ranging experience in all facets of employee benefits, compensation and ERISA matters,

including the design, implementation and operation of retirement plans, health and welfare benefit plans, cafeteria plans,

fringe benefit plans, and non-qualified deferred compensation programs. Magan is a specialist in counseling clients on the

business impact, strategic response, plan design and compliance with health care reform. Magan regularly advises clients,

from startups to Fortune 100 companies, on issues in mergers, acquisitions, spin-offs and joint ventures. Magan also has

experience in representing companies undergoing employee benefits, employment and tax audits before the IRS, DOL and

EDD. She received her J.D., with distinction, from Stanford Law School.

January 30, 2014

50

SEGMENT 3:


ACA Directives Regarding Wellness Programs

> Includes provisions intended to encourage workplace health promotion as a means to reduce the burden of chronic illness, improve health, and slow the growth of health care costs.

> A “wellness program” is defined as a program offered by an employer designed to promote health or prevent disease.

> Interventions directed at healthy behaviors can change the trajectory of long-term health.

January 30, 2014

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SEGMENT 3:


SEGMENT 3:


Wellness Program Recap

> Participatory Wellness Programs

> Health-Contingent Wellness Programs

– Activity-Only Program

– Outcome-Based Program

**Health-contingent wellness programs must meet certain requirements to avoid being deemed discriminatory.

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SEGMENT 3:


SEGMENT 3:


Potential Impact of Wellness Programs

> 1 in 10 Americans has diabetes today.

> CDC projects diabetes rate to be 1 in 3 Americans by 2050.

> Lifestyle interventions (reduce body weight, dietary changes, physical activity) reduce development by 60%.

> Programs are viable strategy to contain health care costs.

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SEGMENT 3:


Increase of Wellness Promotion Initiatives

> Approximately half of U.S. employers with 50 or more employees offer wellness promotion initiatives.

> Wellness benefits can be offered by employers directly to all employees or though group health plans to members.

> 69% of Employers with wellness programs use “rewards” or financial incentives to encourage utilization.

> Most common monetary incentive is Health Risk Assessment (HRA) completion or lifestyle management programs.

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SEGMENT 3:


The Future of Wellness Programs

> Long Term Health Impact of Wellness Programs

– Longer follow up required given latency between health risks and development of chronic disease.

> Impact on Broader Range of Measures

> Absenteeism, Productivity, and Retention are Critical to Employers.

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SEGMENT 3:


The Future of Wellness Programs

> Program Design and Delivery

– Accreditation of certain programs and operation by third parties.

– Address concerns regarding discriminatory programs by permitting a “safe harbor” for those employers who establish conduct for reasonable design of a wellness program.

– Questions remain regarding level of participation and cooperation of physicians in crafting wellness program alternative standards.

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SEGMENT 3:


Case Studies

> Group health plans are prohibited from discriminating against participants with respect to eligibility, benefits, or premiums based on a health factor.

> As an exception to this rule, a properly designed wellness program may provide rewards.

> Not all wellness programs are via a group health plan.

> Participatory Programs do not require an individual to satisfy a standard related to a health factor but must be available to all similarly situated individuals.

> Health-Contingent Programs (Activity-Only or Outcome-Based) require an individual to satisfy a standard and must comply with 5 requirements.

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SEGMENT 3:


5 Requirements for Health-Contingent Programs

> Must have a chance to qualify for the reward at least once per year (frequency).

> Total reward may not exceed 30% of cost of coverage with an additional 20%, for total of 50%, for programs aimed at reducing tobacco use.

> Must be “reasonably designed” to promote health or prevent disease.

> Reward must be available to all similarly situated individuals; must offer a “reasonable alternative standard” (RAS) or waiver.

> Notice of availability of RAS.

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Case Study One – Outside Health Plans

> Employer subsidizes gym membership ($50/month).

– Not part of health plan but ensure proper tax treatment.

> Employer offers to pay for weight loss program for all employees (regardless of whether they are in health plan).

– Not part of health plan but ensure proper tax treatment.

> Employer gives $100 gift certificate to each employee (and spouse) who completes an HRA, which does not ask for family history or other genetic information.

– May/may not be through health plan but ensures tax treatment of gift cards is addressed.

– HRA complies with GINA.

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Case Study Two – Health Risk Assessment

> Employer provides $50 a month premium discount for completion of an HRA and biometric screening, which does not ask for family history or other genetic information and does not base the reward on the information (e.g., whether the employee is a smoker or not or what level blood pressure is).

– HRA complies with GINA.

– This is a Participatory Program and not a Health-Contingent Program because the reward is not based on the outcome of the answers to the HRA or results of biometric screening, so no need to analyze frequency, size of reward, design, RAS, or notice requirements.

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SEGMENT 3:


Case Study Three – Smoking Cessation

> Employer continues with earlier wellness programs and adds a reimbursement for the cost of participating in a smoking cessation program without regard to whether the individual quits smoking.

– This is a Participatory Program because the reward is participation in the smoking cessation program and not the outcome (i.e. quitting smoking).

– As a Participatory Program no need to analyze frequency, size of reward, design, RAS or notice requirements.

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Case Study Four – Exercise Program

> Employer adds a “healthy heart” program which provides $100 premium reduction for participating in a walking program (e.g., 150 minutes per week). Employee only coverage is $400.

> “Healthy heart” is an Activity-Only Health-Contingent Program.

– Should be able to meet frequency, reasonable design and notice requirements.

– Reward of $100 (25%) is within maximum range.

– RAS must be provided if medically inadvisable to attempt , or due to medical condition it is unreasonably difficult, to meet standard.

May seek verification from physician but must take into account recommendations in establishing a RAS.

RAS may include, e.g., other exercise (activity rules apply), diet or education program (must pay for course but not food).

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SEGMENT 3:


Case Study Five – Tobacco Surcharge

> Employer requires a certification (as part of HRA) regarding tobacco use and provides premium reductions of $50/month for completion of HRA and $100/month for certification of no tobacco use.

> Full $100 reward available to tobacco users who certify they will complete a tobacco cessation program without regard to whether they quit.

> This is an Outcome-Based Health-Contingent Program because standard is to be a non-tobacco user.

> Potential frequency issues related to mid-year hires and length of cessation programs.

> Reward of $150 is 37.5% of total cost of employee coverage ($400/$150 = 37.5%) which is within 50% maximum.

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SEGMENT 3:


Case Study Five – Tobacco Surcharge cont’d.

> To meet reasonable design test, smokers must be given a RAS whether or not individual has medical condition or it is medically inadvisable to meet the standard.

– Employer voluntarily established the completion of the tobacco cessation program (without regard to outcome) as a RAS up front.

– The tobacco cessation program is Participatory Program so no further alternatives are required.

– Employer must find and pay for cessation program.

> Notice of availability of RAS must be provided in plan materials that describe program and in disclosure that individual did not meet standard to be tobacco free.

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SEGMENT 3:


Case Study Six– Biometric Levels

> Employer continues HRA/biometric screening and smoking cessation and adds a $50 per month premium reduction if BMI is at/under 28.

> This an Outcome-Based Health-Contingent Program.

> Total available reward $200 ($50 for HRA/biometric screening, $100 for tobacco-free certification/tobacco cessation program, $50 for meeting BMI standard) is within maximum allowable reward.

– $400/$200 = 50% for all rewards.

– $50 for HRA and $50 for BMI tested separately are within maximum for non-tobacco related programs ($400/$100 = 25%).

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SEGMENT 3:


Case Study Six– Biometric Levels cont’d.

> To meet reasonable design test, if BMI exceeds 28, a RAS must be given whether or not individual has a medical condition or it is medically inadvisable to meet standard.

– RAS may be to reduce BMI by 1 point but since RAS is Outcome-Based, individual must be given opportunity to comply with doctor recommendations as a RAS, if doctor joins the request.

– RAS may be a walking program (which must comply with the Activity-Only rules).

– RAS may be a diet or exercise course (employer must pay for course).

> Notice of availability of RAS must be in plan materials that describe the program and with results for those who do not meet the BMI standard.

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SEGMENT 3:


Things to Consider

> Is the wellness program part of the group health plan?

> If not, has the tax treatment and other legal requirements (e.g. ADA) been addressed?

> If yes, have all the compliance issues, e.g. ERISA (reporting, disclosure, fiduciary duties etc.), COBRA, HIPAA, GINA, ACA, been addressed?

> Design of plan is company decision but implementation and ongoing administration are fiduciary duties; have governance issues been addressed?

> How are vendors selected and do the contracts contain appropriate provisions (clear allocation of duties, standards for delivery of services, risk allocation, indemnity, reasonable fees, termination, HIPAA privacy/security etc.)?

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Introduction

Jim Pshock is a leader known for cutting-edge innovation in the healthcare sector. His career spans over 20 years in the

health insurance industry including executive positions in technology, operations, sales, marketing and corporate strategy

with carriers and third-party administrators. Jim has developed a comprehensive and unique expertise in the regulations

related to governing wellness programs and the practical application of incentives to improve employee health.

Jim frequently presents to regional and national audiences, including human resource professionals, occupational health

professionals and insurance industry associations. He also serves on a national committee of HERO, an advocacy group

exploring the innovation and evaluation of worksite wellness. Jim was recognized for his talents receiving the Northeast

Ohio Ernst & Young Entrepreneur of the Year® Award in 2011.

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SEGMENT 4:


Beyond the laws of what’s legal and what’s not – we can’t dismiss why implementing wellness is important.

70

• Chronic diseases related to lifestyle account for 75% of national medical costs.1

• Over the last five years:2

- Employers saw a 34% increase in healthcare spending.

- Employees saw a 40% increase in contributions to healthcare.

• Prior to 2007, only participation could be rewarded.

1 www.cdc.gov/chronicdisease/overview/index.htm2 Towers Watson/National Business Group on Health (2012)

AON Hewitt 2012 Health Care Surveyhttp://www.aon.com/attachments/human-capital-consulting/2012_Health_Care_Survey_final.pdf

Even moderate health improvement could result in significant cost reduction.

Risks Drive Conditions

12%12% 10%10%16%16%

47%47%

“Outcomes-Based” Programs Are GrowingEmployers planning to reward or penalize based on biometric outcomes

other than smoker, tobacco-use status(Towers Watson/National Business Group on Health Annual Survey 2013)

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

2011 2012 2013 2014

Bravo Wellness Fact Sheet

•Technology platform and administrative service company dedicated to the administration of participation, improvement, and outcomes-based wellness incentives•Over 300 unique plan designs managed and tracked for efficacy•Over one million participant screening result records tracked •Winner of numerous business awards with numerous clients winning wellness program success-based awards and recognition•125 full time employees based in Cleveland, OH serving technology and administrative support needs of employers, insurance companies and wellness companies•Experts in designing “cost-neutral” programs that create win/win opportunities•Screening, coaching, HRA and intervention program agnostic; serves as platform to connect the right people with the right resources at the right time•Average participation in annual blood draw and biometric screening: 97%

“Reasonable alternatives” must be provided for all health-contingent wellness programs.

• Activity-only programs can be limited to “medically inadvisable” situations.• Outcomes-based programs must always have an alternative; may be

automatically offered or “upon request.” - A medically sound progress goal IS considered a reasonable alternative (e.g.

have a BMI less than 27.5 or reduce your BMI by 1 point). - Must provide adequate notice of the progress goal (Bravo suggests 60 day

minimum). - Must provide an alternative to the alternative if a medical issue makes the goal

unreasonably difficult or medically inadvisable.

Personal physicians can always provide an alternative goal that is more medically appropriate. Health coaches and physicians of the wellness plan

may suggest a goal but cannot override personal physician recommendations.

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Bravo Best Practice

Cyc

le O

ne

75

How It Can Work In Two Cycles

EXAMPLE HEALTH IMPROVEMENT RESOURCES

HEALTH IMPROVEMENT PROVIDER OR EMPLOYER CONTRACTED•Health Assessment•Health Monitor•Healthy Aging Guide•Healthy Recipe Collection•Symptom Checker•Women’s Health Guide•And so much more!

HEALTH PLAN COVERS•Preventative Services at 100%•Chantax and Nicotine Replacement Therapy•Nutritional Counseling

OTHER PROGRAMS•Offers Financial Planning and Stress Mgmt.•Offers Tobacco Cessation Program•Weight Watchers at Work •Fitness Center Reimbursement•Health Coaching

Participant receives results, client receives aggregate report, health improvement resources are utilized all year.

Reward Categories National Institutes of Health (NIH) Goals

Employer’sGoals

Alternative Goals^

Financial Impact

Body Mass Index ≤ 24.9 kg/m2 Participation

N/A

+ $50/mo.

Blood Pressure ≤ 120/80 mmHg Participation

LDL Cholesterol ≤ 100 mg/dL Participation

Tobacco / Nicotine Negative Negative Complete Cessation Program + $50/mo.

Participant receives results, client receives aggregate report, health improvement tools are utilized. Strategic planning for Cycle 3 and following.

Reward Categories National Institutes of Health (NIH) Goals Employer’s Goals Alternative Goals^ Financial

Impact

Body Mass Index ≤ 24.9 kg/m2 ≤ 27.5 kg/m2- OR - Waist <33 Female/ <35 Male

10% Weight Loss - OR -Move to

Improved Category $30/mo.

Blood Pressure ≤ 120/80 mmHg ≤ 130/86 mmHg Move to Improved Category $10/mo.

LDL Cholesterol ≤ 100 mg/dL ≤ 130 mg/dL Move to Improved Category $10/mo.

Tobacco / Nicotine Negative Negative Complete Cessation Program $50/mo.

Cyc

le T

wo

Sample Improvement Categories

Systolic Diastolic

Desirable Below 120 Below 80

Elevated I 120 - 135 80 - 85

Elevated II 136 - 139 86 - 89

Elevated III 140 - 159 90 - 99

Elevated IV 160 or Higher 100 or Higher

BLOOD PRESSURE (mmHg)

Reduce your LDL cholesterol by 10% from prior year screening

LDL CHOLESTEROL (mg/dL)

10% weight loss or reduce your BMI by 2 points since

prior year screening

BODY MASS INDEX (kg/m2)

Improvement category levels are not intended to identify risk or medical appropriateness. Always consult with your medical doctor before starting any new exercise or nutrition program.

If Bravo does not have prior results, participants will be provided with the information needed to request an alternative goal in the results letter.

Desirable Below 100

Elevated I 100 - 110

Elevated II 111 - 125

Elevated III 126 or Higher

GLUCOSE (mg/dL)

What defines improvement? As an example: If your 2013 screening result for glucose is 126 (Elevated III), you would need to either improve your glucose into the Elevated II range of 111-125 – OR – achieve the employer’s goal at your 2014 screening.

Design Goals For Your Culture & Budget

Medical IssuesBravo works with individuals and their healthcare providers to set personalized alternative goals and complete healthy lifestyle programs when appropriate.

Bravo has classified appeals and alternatives as follows:

• Alternative Requests: Completing an improvement goal or program regardless of a medical issue

• Type One: Disputing the accuracy of results• Type Two: Exceptions due to medical issues

preventing achievement of goal or alternative goal

• Type Three: Progress made off-cycle for non-retroactive rewards

77

Administering Alternatives & Appeals

78

“What if a participant has a genetic issue?”

“Is BMI really fair?”

“Can I use HDL or total cholesterol instead of LDL?”

“Do penalties work better than

rewards?”

“Have any unions agreed to a model like this?”

“Does this impact my employee’s W2?”

“How can we involve

spouses?”“What about new employees and

COBRA participants?”

“Can we test for

nicotine?”

“Does this violate the

ADA?”

“Will people change behavior for $10/month or $50/month?”

“What about privacy concerns?”

“Do screenings need to be done on the clock?”

“How can I avoid having dozens of different premium contributions to manage?”

BE PREPARED WITH ANSWERSBE PREPARED WITH ANSWERS

Bravo’s Data On Spouse Engagement

80

THREE-YEAR STRATEGIC ROLL OUT

YEAR THREEHRA participation and tighter biometric goals with progress

goals introduced

YEAR TWOHRA participation and modified biometric goals with outcomes-

based incentives (added $50/month)

YEAR ONEHRA participation and baseline biometric screening, impacting full premium ($200+/month)

After only one year of applying the outcomes-based model, Southwest General saw a dramatic slowing in the increase in claims. Claims increased by 16% in the initial (participation-based) year, yet by only 1% from year 2 to 3.

81

Year 2 to Year 3 ChangeAfter implementing an outcomes-based program, they saw the following results:

• 99+% participation each year • In year three: 7.6% participants

stopped smoking and of those who failed BMI year two, 16.4% had a BMI reduction of 2 or more points in year three

• Net savings of $124 per employee, per year enabling them to continue to invest in wellness programs

After experiencing a 20% premium increase in their healthcare costs, management introduced a wellness program to accomplish two goals – improve the health of its employees and reduce the cost trend.

• Workers’ compensation expenses have been reduced by two-thirds.

• Elimination of activity impact on healthcare costs while maintaining high participation in health activities and programs.

• Decrease of almost 50% of participants with more than 1 risk factor.

• High program impact - Obese participants lowered from 37.2% to 31.2%. High LDL cholesterol has had a relative decrease of more than 50%. High blood pressure has gone down 80% amongst Graco participants.

2013 Honorable Mention

$320.00 $311.00

$328.00

$426.00

$529.00 $564.00

$189.00

$215.00

$193.00 $150.00 $200.00 $250.00 $300.00 $350.00 $400.00 $450.00 $500.00 $550.00 $600.00

2008 2009 2010 2011 2012

Employee Spouse Child

Graco’s Medical And Pharmacy Cost Trends

Measure 2008 2009 2010 2011 2012 Total

Safety Incident Rate 5.71 3.77 4.24 3.63 3.60

Workers’ Compensation Expense $452,000 $273,000 $345,000 $145,000 $124,000

WC Expense Reduction (from 2008 baseline) $179,000 $107,000 $307,000 $328,000 $921,000

Measure 2009 2010 2011 2012 Total

Med-Pharm Claims -$265,015 $1,243,604 $1,623,789 $1,569,109 $4,171.487

Workers’ Compensation $179,000 $107,000 $307,000 $328,000 $921,000

Total Financial Impact -$86,015 $1,350,604 $1,930,789 $1,897,109 $5,092,487

Workers’ compensation expense reduction

Total financial impact on medical/pharmacy trend and workers’ compensation expense

Med-Pharm claims show cost avoidance assuming employees health care costs would have trended at the same rate as spouses without a wellness program.

Graco’s Financial Impact

► You may ask a question at anytime throughout the presentation today. Simply click on the question mark icon located on the floating tool bar on the bottom right side of your screen. Type

your question in the box that appears and click send.

► Questions will be answered in the order they are received.

Q&A:

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