Md. Code Regs. 17.04.13.10

Current through Register Vol. 51, No. 12, June 14, 2024

Section 17.04.13.10 - Wellness Program

A. Definitions.

(1) In this regulation, the following terms have the meanings indicated.

(2) Terms Defined.

(a) "Conscientious, objection" means a statement that the individual holds sincere beliefs or practices of a religious, moral, or cultural nature that prohibit the individual from participating in one or more of the healthy activities requirements or in the Wellness Program as a whole.

(b) "Department" means the Department of Budget and Management.

(c) "Director" means the individual appointed to manage the Employee Benefits Division or unit of the Department with primary responsibility of managing the Program.

(d) Health care provider" has the same meaning as "health professional" in State Personnel and Pensions Article, § 9 - 504(b), Annotated Code of Maryland.

(e) Healthy activities requirements" means those activities that must be completed in order for an individual to obtain the full rewards available under the Wellness Program.

(f) Reasonable alternative" means an activity that may be substituted for a healthy activities requirement and that may provide an individual with an alternate method of qualifying for the opportunity to earn the full rewards available under the Wellness Program.

(g) Reward" means:

(i) Obtaining an incentive, such as a waiver of all or part of a cost-sharing mechanism, which may include deductibles, copayments, or coinsurance; and

(ii) Avoidance of a penalty, such as the absence of a surcharge or other financial or nonfinancial disincentive.

(h) Waiver" means a determination by the Director's designee to exempt an individual from participating in the Wellness Program

(i) Wellness Program" means the program within the State Employee and Retiree Health and Welfare Benefits Program and described in this regulation and in the Guide to Your Health Benefits provided by the Department for the current plan year.

B. General Provisions and Scope of the Wellness Program.

(1) There is a Wellness Program that is administered by the Department.

(2) The Wellness Program has been designed to comply with all applicable State and federal laws, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Patient Protection and Affordable Care Act (ACA), and the Genetic Information Non-Discrimination Act (GINA) of 2008.

(3) The Wellness Program applies to employees, non-Medicareeligible retirees and non-Medicare-eligible enrolled spouses, subject to the following:

(a) If the retiree is Medicare-eligible, but the spouse is not, the spouse is exempt from the wellness requirements; and

(b) The Wellness Program does not apply to retirees and retirees' spouses for whom Medicare is primary.

(4) During years 2015 and 2016, the Wellness Program does not apply to enrolled children regardless of age. The Wellness Program may be expanded in future years to include children, as may be described in the Guide to Your Health Benefits provided by the Department for the applicable year.

(5) Each individual to whom the Wellness Program applies shall have the opportunity to qualify for the rewards at least once per year.

C. Waivers.

(1) The Wellness Program includes the opportunity to request a waiver from participating in the Wellness Program as a whole or from participating in one or more of the healthy activities requirements on the basis of conscientious objection.

(2) An individual who obtains a waiver from participating in the Wellness Program may not qualify for incentive-based rewards or be subject to a surcharge or other financial or nonfinancial disincentive.

(3) Request for a Waiver.

(a) A request for a waiver shall be submitted in writing to the Employee Benefits Division and shall be signed by the individual who is seeking the waiver.

(b) A request for a waiver shall include a statement that articulates the sincerely held belief or practice of a religious, moral, or cultural nature that prohibits the requestor from participating in the healthy activities requirements, and an explanation of how the beliefs or practices prohibit such participation.

(4) Committee to Review Requests for Waivers.

(a) The Director may designate two or more employees as members of a Waiver Committee, consistent with the specifications of this regulation, to review and evaluate requests. At least one employee member shall be from the Employee Benefits Division of the Department's Office of Personnel Services and Benefits.

(b) For each request, the Waiver Committee shall make a recommendation to the Director's designee to grant or deny the request, or to request additional information from the requestor.

(c) The Director's designee has discretion to accept or reject the recommendation and may request additional information from the Waiver Committee or from the requestor.

(5) Determination by the Director's Designee.

(a) The Director's designee shall issue a written determination approving or denying the request for a waiver as soon as practicable.

(b) Approval or denial of the request for a waiver is discretionary, subject only to abuse of that discretion, and may be based on any legally permissible reason.

(c) A determination approving a request for a waiver shall state the healthy activities to which it applies.

(d) A determination denying a request for a waiver shall include instructions for requesting reconsideration.

D. Reasonable Alternatives.

(1) The Wellness Program shall allow a reasonable alternative to or exemption from the healthy activities requirements for:

(a) Any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the healthy activities requirements; and

(b) Any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the healthy activities requirements.

(2) Request for a Reasonable Alternative.

(a) A request for a reasonable alternative shall be submitted in writing to the Employee Benefits Division and shall be signed by the individual who is seeking the reasonable alternative, the individual's Power of Attorney, or another individual otherwise authorized to act on behalf of the individual.

(b) A request for a waiver shall include a statement that articulates the basis for the request.

(c) A request for a reasonable alternative to the healthy activities requirements may include documentation that supports the stated basis for the request. Where an individual provides credible support that it is unreasonably difficult due to a medical condition to satisfy the healthy activities requirements or that it is medically inadvisable to attempt to satisfy the healthy activities requirements, a reasonable alternative shall be permitted, or the individual shall be exempted from the healthy activities requirement.

(d) A reasonable alternative determined by the individual's health care provider shall be permitted upon the individual's request.

(e) The Director's designee may request verification, in the form of a signed and dated statement from the individual's health care provider, that a health factor makes it unreasonably difficult for the individual to satisfy, or medically inadvisable for the individual to attempt to satisfy, the healthy activities requirements in an activity-only wellness program.

(f) If the individual's health care provider states that a healthy activities requirement is not medically appropriate for that individual, the Director's designee shall permit a reasonable alternative that accommodates the recommendations of the individual's health care provider with regard to medical appropriateness, which may include an exemption from the healthy activities requirements.

(g) A health care provider's recommendation for a reasonable alternative or statement in support of a request for a reasonable alternative, which may include exemption, shall be on official letterhead, signed and dated, in order to be considered.

(3) Determination by the Director's Designee.

(a) The Director's designee shall issue a written determination approving or denying the request for a reasonable alternative as soon as practicable.

(b) Approval of a request for a reasonable alternative is discretionary, subject only to abuse of that discretion, and denial may be based on any legally permissible reason.

(c) A determination authorizing a reasonable alternative shall describe the reasonable alternative and, if appropriate, state the healthy activities to which it applies.

(d) A determination denying a request for a reasonable alternative shall include instructions for requesting reconsideration.

E. Reconsideration.

(1) An individual may request reconsideration of the determination denying a request for waiver or reasonable alternative.

(2) A request for reconsideration must be submitted to the Director within 10 days of receipt of the determination.

(3) A request for reconsideration shall state the reasons the individual believes the determination should be reconsidered and may be accompanied by supporting documentation.

(4) The Director or designee shall issue a response to the request for reconsideration in writing within 30 calendar days of receipt of the request. The designee may not be the same employee who issued the underlying written determination.

F. Confidentiality of Medical Documentation.

All medical documentation submitted with a request for waiver or reasonable alternative shall be treated as confidential and shall be disclosed only as permitted by applicable law and only to those individuals who need to know its contents as part of the review, evaluation, determination, and reconsideration process, in accordance with the ACA, HIPAA, and GINA.

Md. Code Regs. 17.04.13.10

Regulation .10 adopted effective 42:15 Md. R. 1016, eff.8/3/2015