Rules for wellness programs under Medicaid

Wellness programs, also known as healthy behavior programs, give health plan enrollees incentives to engage in healthy behaviors or reach certain health benchmarks. HHS has approved wellness programs as a part of some Medicaid adult coverage waivers.

Good wellness programs can encourage appropriate preventive care or help people improve their health. However, if not well structured, they can make it harder for people to get the care they need or keep coverage, or may discriminate against individuals based on their health status.  

Wellness programs and Medicaid adult coverage waivers: Focus on making them work well 

It will probably be hard to keep wellness programs out of Medicaid.

As of June 2015, CMS had approved all state requests to include wellness programs in Medicaid expansion waivers. Given that, the best advocacy approach is probably to focus on making sure the program is structured to benefit consumers

If a wellness program is part of the Medicaid: Suggestions for making it work for consumers

Do not impose requirements immediately upon enrollment. 

  • Give enrollees time to meet wellness requirements: Allow enrollees time to get used to having and using health care coverage and time to develop relationships with sources of care before imposing any wellness requirements or associated penalties. For example, allow enrollees six months to a year to get a physical. Do not impose cost-sharing during that time. 

Use activities, not outcomes, as a measure of success.

  • Base the program on enrollees' completion of a positive behavior: Make activities the wellness goal, such as getting a check-up, rather than outcomes, such as weight loss or blood pressure targets. Individuals may not meet outcome targets for a variety of reasons, many outside of a patient's control. Outcome targets can be punitive and actually make it harder for people with health risks to get the care they need to address those health problems before they worsen.

Base the program on activities shown to improve health.

  • Use peer-reviewed programs: Choose wellness program activities based on peer-reviewed medical data showing a solid connection between that activity and improved patient health. 

Make it easy for enrollees to comply.

States with Wellness Program Waiver Element

  • Waive copays or other costs: There should not be any copay or other cost-sharing associated with activities connected with the wellness program goals. 
  • Make sure the program works with your state's Medicaid program: Make sure the program makes sense given your state's Medicaid program and provider networks. For example, in a rural state where getting to a doctor may be difficult, allow consultations with ancillary providers to complete the wellness goal. 
  • Keep non-emergency medical transportation as a benefit: States that include wellness requirements should make it as easy as possible for enrollees to meet those requirements. This includes providing certain Medicaid benefits, such as non-emergency medical transportation, that make it easier for enrollees access the health system. 

Do not make enrollees repeat activities needlessly.

  • Give enrollees "credit" for wellness goals completed prior to their Medicaid enrollment: If a new Medicaid enrollee has met the program's wellness requirement before he or she was enrolled in Medicaid, e.g., had a physical in the prior 12 months, allow that to count as meeting the goal for Medicaid. Repeating activities is inconvenient for enrollees and increases health care costs.

Keep the program simple.

  • Avoid multiple requirements or goals: Programs with multiple requirements or multiple goals can be confusing for enrollees, making it harder for them to comply. Confusing and complicated programs also add to state administrative costs. 

Include education and support.

  • Incorporate simple, frequent enrollee communications: Make sure enrollees understand the program. At enrollment, and frequently afterward, enrollees should get simple communications, in the enrollee's preferred language, about the program and reminders if activities have not been completed. Use multiple forms of communication (e.g., mail, text message, email, telephone). 

Use rewards, not penalties.

  • Do not link programs to financial penalties or benefit levels: Enrollees should not incur a financial penalty or lose benefits for failing to complete wellness requirements. Base programs on positive incentives. New York's Medicaid Incentives Program gives enrollees cash rewards or lottery tickets for taking steps to reduce their risk of chronic conditions.  
  • If using rewards isn't possible, use the program to reduce enrollee costs: It may not be possible to incorporate positive incentives into Medicaid wellness programs. In adult coverage programs with cost-sharing or premiums, meeting wellness activities can be a way to have those costs reduced or waived.

Structure timing of rewards and goal completion to maximize program effectiveness.

  • Don't delay rewarding the behavior: Research shows that immediately rewarding individuals when they complete a healthy behavior is more likely to produce long-term behavior changes. Don't make enrollees wait months before receiving a benefit once they complete the wellness goal. 
  • Don't set deadlines for getting rewards: Avoid setting deadlines; allow enrollees to get the benefit whenever they complete the behavior. Setting deadlines, e.g., getting a check-up within three months of enrollment or no benefit accrues, can discourage enrollees from engaging in a valuable healthy behaviors if they miss the deadline.

Start making the case to change the program if it isn't working for consumers.

  • Collect evidence of the impact on consumers. Legislation and waivers can be modified. If the state's wellness program is not working for consumers, document that using program data and stories from consumers and providers. Build a case to restructure the program.
  • Include a robust data collection and evaluation component: Learn from states that have evaluated wellness programs in their waivers. Contact researchers and advocates in those states to learn about their approaches for program evaluation. For example, University of Iowa researchers released a report tracking the expansion population's experience with wellness programs
  • Plan a campaign with a broad coalition. Reach out to groups that might be interested in working with you to advocate for program changes. 
  • Keep track of how programs are working in other states: Stay abreast of Medicaid wellness program evaluations. Data on what does and doesn't work in other states can help you make the case to improve the program in your state.