Federal law prohibits discrimination in eligibility, benefits or premiums based on a health factor in group health plan coverage, but an exception lets a plan offer premium discounts or rebates, or changes to cost sharing or benefits, in return for following certain programs of health promotion and disease prevention, commonly called wellness programs. A premium discount tied to a screening that records your weight and BMI comes from one of these programs. Once you know whether your discount is paid for completing the screening or for the result it records, you can tell which protections apply to you and what to ask before you say no.
What skipping the screening can cost you
Skipping the screening can cost you money if completing it is one of the conditions for the program's reward. That reward can take several forms, among them a discount or rebate of a premium or contribution and the absence of a surcharge, so saying no can mean losing a discount or paying a surcharge. What the federal rules then require of the plan depends on what the conditions are. In a participatory wellness program, none of the conditions for obtaining a reward is based on an individual satisfying a standard related to a health factor. In a health-contingent program at least one condition is a standard of that kind, such as not smoking, attaining certain results on biometric screenings, or meeting targets for exercise.
Participatory programs include a diagnostic testing program that does not base rewards on test outcomes, a fitness center reimbursement program, and a program that rewards attending health education seminars. If your form pays you for turning up to the screening, it is built like the first of those, and the number on the scale plays no part in whether you get the discount.
Where the discount does depend on your result, the amount at stake is capped. The reward from all of a plan's health-contingent programs together must not exceed 30 percent of the total cost of employee-only coverage, and the maximum is 50 percent for programs designed to prevent or reduce tobacco use. If any class of dependents can take part, the limit is 30 percent of the total cost of the coverage you and your dependents are enrolled in.
Which kind of program a weight and BMI screening is
The screening counts as participatory when the payment follows the appointment, and as health-contingent when it follows the number. A health-contingent program is either activity-only, requiring you to perform or complete an activity related to a health factor to obtain the reward, or outcome-based, requiring an individual to attain or maintain a specific health outcome. A discount for reaching or keeping a set weight or BMI asks you for an outcome.
| What earns the discount | Kind of program | Whether your weight or BMI result changes it |
|---|---|---|
| Completing the screening | Participatory | No |
| Performing or completing an activity related to a health factor | Health-contingent, activity-only | No; completing the activity does |
| Reaching or keeping a set weight or BMI | Health-contingent, outcome-based | Yes, unless you complete a reasonable alternative standard or the plan waives the standard |
The requirements in the next section are written for outcome-based programs, and those for activity-only programs are similar but not identical.
Another way to get the discount when it turns on your number
An outcome-based program has to offer you one: a reasonable alternative standard, or a waiver of the otherwise applicable standard, for anyone who does not meet the initial standard based on the measurement, test or screening. A reasonable alternative standard is a different way to qualify for the reward, and a waiver sets the standard aside for you.
Alongside that alternative, an outcome-based program has to meet these requirements:
- It gives you an opportunity to qualify for the reward at least once a year.
- It is reasonably designed to promote health or prevent disease, which means it has a reasonable chance of improving health or preventing disease, is not overly burdensome, is not a cover for discriminating based on a health factor, and does not use a highly suspect method.
- All plan materials describing its terms disclose that the alternative or a waiver is available, with contact information for obtaining the alternative and a statement that recommendations of your personal physician will be accommodated.
Since the notice has to say that your personal physician's recommendations will be accommodated, ask the contact it names how to send in your own doctor's recommendation if you have one.
A packet that says nothing about an alternative is not necessarily breaking the disclosure requirement. If plan materials merely mention that such a program is available, without describing its terms, the disclosure is not required. A summary of benefits and coverage that only says your cost sharing may vary with an outcome-based program, without describing its standards, does not have to mention the alternative. The notice is owed in materials that describe the terms, and in any notice telling you that you did not meet an outcome-based standard.
If the materials that describe the terms of a program whose discount depends on your result give no alternative and no contact for one, and your coverage is a private sector job-based plan, contact the Employee Benefits Security Administration at the Department of Labor, at askebsa.dol.gov or toll-free on 866-444-3272, which helps employers and workers with private sector job-based retirement and health plans. For a government employer's plan, ask your employer's benefits office which agency oversees it.
If you finish the alternative partway through the plan year, a plan that does not otherwise provide the reward back to the start of the year need only pay it from the date you finish, under enforcement relief the Departments of Labor, Health and Human Services and the Treasury issued on August 26, 2026, which lasts until further guidance or regulations are issued. HHS has also encouraged the states with primary authority to enforce these rules against insurers to take a similar approach. The program must still provide sufficient time for individuals to complete the alternative standard and receive a reward. Because the reward may start only when you finish, ask the contact your plan materials name for the alternative as soon as you know you will need it.
What your employer ends up seeing of your result
Your employer's view of your result depends on whether the program sits inside your group health plan, where your individual result is protected under HIPAA, the federal health privacy law, or is offered by your employer directly, where it is not. HIPAA's rules apply to the group health plan your employer sponsors, which is a covered entity, one of the kinds of organization those rules bind, and not to your employer in its capacity as an employer. Other federal or state laws may apply to the health information an employer collects in a program it offers directly.
Inside the plan, what reaches your employer without your written authorization depends on whether it helps run the plan:
- If your employer administers parts of the plan, including wellness benefits offered through it, the plan may give it the protected health information necessary to perform its plan administration functions, but only after your employer amends the plan documents and certifies that it will, among other things, keep the employees who do plan administration separate from those who do not, and not use or disclose the information for employment-related actions.
- If your employer does not administer the plan, the plan generally may disclose to it only which individuals are taking part in or enrolled in the plan, and summary health information if your employer asks for it to modify the plan or obtain premium bids.
An employee welfare benefit plan with fewer than 50 participants that administers itself is not a group health plan under HIPAA's rules, so it is not a covered entity under them, and the limits above on what a plan may pass to your employer do not bind it.
A screening result is not protected by HIPAA just because it is health information. The Privacy Rule does not protect your employment records, even if the information in those records is health-related, and in most cases it does not apply to the actions of an employer. Your employer can ask you for health information if it needs it for sick leave, workers' compensation, wellness programs or health insurance; the rule controls how a health plan or a covered health care provider shares your information with an employer. For a question about the plan itself, use the EBSA contact above. For an issue with your employer, the Department of Labor's line is (866) 4-USA-DOL and the Equal Employment Opportunity Commission's is (800) 669-4000.
Questions for your employer's benefits office
Federal rules govern what a plan may do, and what your own company's screening sends to its own staff is something your plan's own documents and contacts can tell you. Ask your employer's benefits office, or the wellness contact your enrollment materials name, before you sign up or decline:
- Is the discount paid for completing the screening, or for the result?
- If it is paid for the result, what is the reasonable alternative standard or waiver, and how do I send in my own doctor's recommendation?
- If I decline the screening altogether, can I still earn the discount another way?
- If I complete the alternative partway through the plan year, is the reward paid back to the start of the year?
- Is the wellness program part of the group health plan, or offered by the company directly?
- Does the company, as plan sponsor, receive my individual result, or only enrollment and summary health information?
If the screening takes your blood pressure as well and the reading worries you, talk to the health care team at your own doctor's office, who can also tell you how often to have your blood pressure measured (see Why your prescriber needs your home blood pressure log).
NicoCares asks for your height and weight too, along with your health history, in its eligibility check. Your answers go to the physician who reviews you, the pharmacy that fills a prescription written for you and, once you have an account, your care team through secure messaging on Spruce Health, among others, and NicoCares does not sell them or use them for advertising.
