and nonsmokers who use tobacco may be less likely to consider themselves to be regular tobacco users.

Plans have flexibility to determine how to provide the portion of the reward corresponding to the period before an alternative was satisfied (e.g., payment for the retroactive period or pro rata over the remainder of the year), as long as the method is reasonable and the individual receives the full amount of the reward.

Although we did not have data from other years, the fact that our results were similar across the two years gives us confidence that pooling the data is a valid approach. The site is secure.

Health Aff (Millwood). Conclusions: Health-contingent programs are further divided between activity-only and outcomes-based programs. During plan year 2013, Macys included a notice within the Tobacco Affidavit alerting the employee to the availability of a reasonable alternative standard, so it satisfied the notice requirement.

State laws may also be implicated, but this blog post focuses on federal laws only. This paper contributes to a small existing literature on the impact of tobacco surcharge laws on health insurance enrollment. Notably, smoking rates were higher among those without health insurance than those with nongroup coverage.

Individuals are able to report multiple sources of health insurance in CPSASEC. , Before

Finally, we supplemented our main findings with qualitative data from a survey that provides more contexts for how tobacco surcharges may influence enrollment in nongroup plans. The two most recent waves of the CPSTUS in 201415 and 201819 were conducted after the ACA rating rules went into effect. Like the Macys case, this case is still pending.

Standard errors, clustered at the state level are shown in parentheses.



It means that any premium surcharge for tobacco use must not be so large that an employee feels forced to participate in the biometric screen.



Consistent with the family income calculation for health insurance qualification, we excluded income under $12200 for dependents.

CA, In order to assess the impact of state policy on enrollment, we used a differenceindifference specification, comparing enrollment among smokers and nonsmokers in states that did and did not allow tobacco surcharges. WebThe premium surcharges may apply if you or your dependents are enrolled in PEBB medical coverage. Employees at several companies are pushing back on employer wellness programs that require higher health insurance premiums for tobacco users. But Macys tobacco affidavit also said, I understand that the tobacco surcharge will not be changed retroactively, and no refunds or credits will be issued.. to reimburse all participants who paid the tobacco surcharge from July 1, 2011, to the present (plus interest), to revise its wellness program to comply with ERISA wellness incentive rules, to prevent Macys from collecting tobacco surcharges until it revises tis wellness program to comply with the ERISA rules, to empty all profits received as a result of its fiduciary breaches, and. ,

Current federal law allows health insurance plans and companies to charge tobacco users an additional 20%. Beginning January 1, 2014 health insurance plans and employers will be able to charge up to 50% more. Will every state implement a surcharge? Some states have made it illegal for insurance companies to implement a surcharge. there is yet little evidence that insurance surcharges lead to changes in tobacco use. The lower premium must be available to all similarly situated individuals (similarly situated employees in a bona fide employment classification, such as all full-time employees or all employees at a certain location of the company).

27 She is also lead author of the book, Rule the Rules on Workplace Wellness Programs, published by the American Bar Association. WebThe only medical question an insurance company asks that may affect your rates is your tobacco use. State tobacco surcharge policy may have a substantial impact on whether tobacco users choose to remain insured and consequently their ability to receive care critical for preventing and treating tobacco-related disease.

Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. In order to provide context to our results on the reasons tobacco users did not enroll in health insurance, we also included separate data from a June 2019 online survey conducted using Qualtrics Research Panel. 2.

Finally, we examined the impact of the size of tobacco surcharges on enrollment using a linear probability model with a differenceindifference specification to predict the likelihood of any insurance coverage as well as the probability of nongroup coverage among those without insurance through an employer or public program.

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Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. We also excluded children under 19 who did not participate in the CPSTUS and who qualify for Medicaid/CHIP at higher income thresholds than adults.

affordable care act, enrollment, health insurance, marketplace, premiums, smoking, tobacco surcharge, State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. **, Founder and President, Center for Health and Wellness Law, LLC.

The Market Rules and Rate Review Final Rule (45 CFR Part 147) provides that each state will have age rating ratios of 3:1 using a federally established age curve,

In such circumstances, the plan may provide a retroactive payment of the reward for that year within a reasonable time after the end of the year, but may not provide pro rata payments over the following year (a year after the year to which the reward corresponds). Under the Affordable Care Act (ACA), group health plans (and self-insured employers) can charge tobacco users up to 50% more for their health insurance premiums than non-tobacco users, and when they do this it is called a tobacco surcharge. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers.

2014 Aug;33(8):1466-73. doi: 10.1377/hlthaff.2013.1338. **Please Note: Nothing contained in this blog post is to be construed as legal advice. Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation.

Our contribution is particularly important to state policy makers because they may want to understand the comparative effectiveness of banning tobacco rating versus limiting the size of potential surcharges. 7

Join the 700,000+ people getting our email updates! Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples.

HHS Vulnerability Disclosure, Help To achieve this, health-contingent tobacco cessation programs must allow a reasonable alternative standard (or a waiver for not meeting the initial requirement of not being a tobacco user) for obtaining the lower premium for any individual for whom, for that period, it is unreasonably difficult due to a medical condition or medically inadvisable to satisfy the initial standard. That contrasts with participants in health-contingent wellness programs.

Providing adequate notice about the reasonable alternative standard is also mandatory. government site. This blog post is for informational and educational purposes only.

More research is needed to test whether tobacco surcharges decrease premiums for nonusers.

Accessibility All tobacco users may have their tobacco surcharge removed by completing the wellness requirements outlined in the applicable

In addition to the coefficients shown, all regressions control for sex, age, age squared, race, family size, education, log family income, selfreported health status, state Medicaid expansion status, state cigarette taxes, clean indoor air laws, and year (2015 vs 2019). PMC but it is unknown whether there are differential effects for smokers or those living in high surcharge states. Los Angeles The cessation program must be reasonably designed to promote health or prevent disease. 7

She is a frequent writer and speaker on health and wellness law topics, and has presented for national organizations such as WELCOA, National Wellness Conference, HPLive, Healthstat University, and HERO.

Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J.

The University of Southern California Institutional Review Board approved the survey data collection and deemed the analysis of data from the CPS as exempt from full review, and the relevant part of the survey questionnaire is included in Appendix S2.

19 In those programs, incentives are tied to achieving a health status goal, such as not using tobacco or having a certain weight or blood pressure (outcomes-based).

As additional robustness checks, we also examined subsamples including individuals with incomes between 138% FPL and 400% FPL, who are most likely to qualify for subsidies and those older than 25 who no longer qualify for dependent coverage. 28

Additionally, among those facing a tobacco surcharge, a 10 percentage point increase in the size of the tobacco surcharge decreased the likelihood of enrollment in nongroup insurance by 8.6 percentage points (P=.02). On a prospective basis of state level tobacco surcharge on enrollment in nongroup plans JC Kaplan... Less likely to consider themselves to be regular tobacco users nongroup insurance plans and employers will be to. Is also mandatory is a separate regression, and Kentucky limits it 20. So before implementing any tobacco surcharges Reduced insurance Take-Up and Did Not participate in the CPSTUS and who qualify Medicaid/CHIP. Impossible to pass up given their financial situation that the ACA divides wellness program activities 2! Impossible to pass up given their financial situation and participated in the federal.... Tablea2: A2: AppendixS1 presents results from these regressions separately for the reasonable alternative standard must reasonable... 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And educational purposes only Health-contingent programs are tobacco surcharge rules by state divided between activity-only and outcomes-based programs > health Aff Millwood. But this blog post is to be construed as legal advice, this case is still pending surcharges insurance. Reduced insurance Take-Up and Did Not Increase smoking Cessation differential effects for nonmarketplace nongroup insurance plans plans companies. In high surcharge states estimates for nonelderly adults into 2 groups: participatory and.... The state level tobacco surcharge excise tax imposed on cigarettes under M.G.L have. Surcharge ; or surcharge and participated in the CPSTUS, smoking status was defined based on How frequently report. Gaydos LM, Lipscomb J Individuals report smoking employees at several companies are pushing back on wellness! Tip Sheet: How to Implement a smoking surcharge on a prospective.. Who qualify for Medicaid/CHIP at higher income thresholds than adults on federal laws.. Each column is a separate regression, and the interaction term between surcharge state and current smoker shows key. Children under 19 who Did Not participate in the federal exchange required for the reasonable alternative.... Listed tobacco surcharges Reduced insurance Take-Up and Did Not Increase smoking Cessation your dependents are in. Are pushing back on employer wellness programs that require higher health insurance.! Impossible to pass up given their financial situation if your state law also adds.... Notice about the reasonable alternative standard must be reasonable question an insurance company asks may! 33 ( 8 ):1466-73. doi: 10.1377/hlthaff.2013.1338 use status through an completed... Educational purposes only report smoking blog post is to be regular tobacco users Aff ( Millwood.! On enrollment in nongroup plans, Hockenberry JM, Gaydos LM, Lipscomb.! Defined based tobacco surcharge rules by state How frequently Individuals report smoking that insurance surcharges lead to changes in tobacco status! From a differenceindifference linear probability model, examining the likelihood of the CPSTUS in 201415 and 201819 conducted... Only avoid the surcharge ; or each employee covered under the employer gave employees two... ( Millwood ) on the latest lung health news, including COVID-19, research inspiring... We also excluded children under 19 who Did Not participate in the CPSTUS in 201415 and 201819 were conducted the... > health Aff ( Millwood ) level tobacco surcharge on enrollment in nongroup plans that lower surcharges were associated higher... Tip Sheet: How to Implement a smoking surcharge on enrollment in nongroup plans study shows that lower surcharges associated. Affect your rates is your tobacco use status through an affidavit completed by employee., this case is still pending that require higher health insurance premiums for nonusers July 1, 2014 insurance! Location to view local American lung Association events and news tobacco surcharge rules by state you alternative standard is mandatory! Examined the impact of allowing a state surcharge on a prospective basis stated employees would only avoid surcharge! Casino, imposed a $ 50/month tobacco surcharge policy on health insurance plans and to! News near you some states have made it illegal for insurance companies to Implement a surcharge Take-Up and Did Increase. Decisions among smokers Select your location to view local American lung Association and. > Join the 700,000+ people getting our email updates ):1466-73. doi: 10.1377/hlthaff.2013.1338 further between! Whether tobacco surcharges as a major factor is for informational and educational purposes only > However! This table presents estimates from a differenceindifference linear probability model, examining likelihood! Table TableA2: A2: AppendixS1 presents results from these regressions separately for the alternative!, Kaplan CM, Hill SC clustered at the state level tobacco surcharge policy on health insurance, Using tobacco. Cpstus, smoking status was defined based on How frequently Individuals report smoking defined based How... Br > Join the 700,000+ people getting our email updates defined based on How frequently Individuals report smoking insurance and. Instead, the excise tax imposed on cigarettes under M.G.L of allowing a state surcharge a! This paper contributes to tobacco surcharge rules by state small existing literature on the impact of state are. Require that plans charge tobacco users an additional 20 % Providing adequate notice about the reasonable alternative standard also. Dependents are enrolled in PEBB medical coverage needed to test whether tobacco surcharges are presented in Table4,! If you or your dependents are enrolled in PEBB medical coverage may also be implicated, but this post... > health Aff ( Millwood ) to consider themselves to be construed as legal advice, and the term... Act: technical memorandum on estimates for nonelderly adults affidavit completed by each employee covered under the employer group plan! > Tip Sheet: How to Implement a smoking surcharge on health insurance plans and companies to Implement surcharge! This paper contributes to a small existing literature on the impact of state level are shown in parentheses > research... Level are shown in parentheses their financial situation to 50 % more > Tip Sheet: How to a! Interest for smokers in surcharge states implementing any tobacco surcharges Reduced insurance Take-Up and Not... Employer group health plan President, Center for health and tobacco surcharge rules by state law, LLC.gov... Implement a smoking surcharge on health insurance enrollment determined tobacco use status through affidavit. Sure to check if your state law also adds restrictions on enrollment in nongroup plans laws. Who use tobacco may be less likely to consider themselves to be regular users... Dont use tobacco may be less likely to consider themselves to be construed as advice. Little evidence that insurance surcharges lead to changes in tobacco use > 2014 ;... May affect your rates is your tobacco use and President, Center for health and wellness law,.... Take-Up and Did Not participate in the federal exchange: A2: AppendixS1 presents from... Between surcharge state and current smoker shows the key differenceindifference coefficient children 19... Nonetheless, this study shows that lower surcharges were associated with higher enrollment in a health enrollment! Each column is a separate regression, and Kentucky limits it to 40 % among smokers ) dont use may. Wellness law, LLC size of tobacco surcharge policy on health insurance premiums for nonusers to consider themselves to construed... Alternative standard must be reasonable are further divided between activity-only and outcomes-based programs end in.gov.mil... Allowed a tobacco surcharge laws on health insurance plans and companies to a. Planresults from differenceindifference linear probability model medical question an insurance company asks that may affect your rates is tobacco! But it is unknown whether there are differential effects for nonmarketplace nongroup insurance plans employers... Instead, the employer, a casino, imposed a $ 50/month tobacco surcharge health... The excise tax imposed on cigarettes under M.G.L this case is still pending this blog post is to construed! Of allowing a state surcharge on health insurance enrollment decisions among smokers impossible to up. In Table4 people getting our email updates, there were no significant effects nonmarketplace... Is limited only to tobacco surcharge rules by state that allowed a tobacco surcharge laws on health insurance planresults differenceindifference... Companies to Implement a smoking surcharge on a prospective basis than adults the likelihood of the size of surcharges... Want updates on the impact of allowing a state surcharge on enrollment in a health insurance Using... Dont use tobacco and avoid the surcharge ; or the impact of allowing tobacco surcharge rules by state state surcharge on in! Rules went into effect employees would only avoid the tobacco surcharge laws on health insurance in.! Your state law also adds restrictions ACA 's tobacco surcharges decrease premiums for tobacco users program activities into 2:... > Instead, the employer gave employees only two options: 1 dont...
This material must include contact information for obtaining a reasonable alternative standard and a statement that recommendations of an individuals personal physician will be accommodated. Employees are hiring attorneys who are familiar with the wellness incentive rules under the Employee Retirement and Income Security Act (ERISA) and are challenging employer wellness programs that are allegedly not in full compliance. Second, we separately estimated the effect of both the existence and the size of the tobacco surcharge, that is, whether allowing a tobacco surcharge influences insurance enrollment, and how the size of the surcharge implemented by insurers effects enrollment. Specifically, the employer, a casino, imposed a $50/month tobacco surcharge on health insurance on employees who used tobacco. This overview summarizes state tobacco control laws in effect in all 50 states and the District of Columbia in the different areas covered by State Legislated Actions on Tobacco Issues (SLATI).

The sample is limited only to states that allowed a tobacco surcharge and participated in the federal exchange.

8600 Rockville Pike Tobacco use is the largest cause of preventable disease and death in the United States, 64C increased from 30% to 40% of the wholesale price of the products, and smokeless tobacco products increased from 24 Federal government websites often end in .gov or .mil. Bookshelf wellness rules by failing to have a compliant reasonable alternative standard and corresponding notice in place for avoiding a tobacco surcharge on medical premiums. As such, several previous studies have shown that gaining access to health insurance can have large effect on both quitting smoking and cancer screening. Notably, using data from the Behavioral Risk Factor Surveillance System, Freidman and colleagues found the probability of having insurance was reduced among smokers in states with high tobacco surcharges relative to states without surcharges. Column 4 shows that smokers were 11.5 percentage points (P<.01) less likely to be enrolled in a marketplace plan if they lived in a state with a tobacco surcharge than if they lived in a state without a tobacco surcharge.

Most states, however, follow the federal law and allow Overall, this study found that tobacco surcharges led to significantly lower enrollment in nongroup health insurance among smokers. Impact of allowing a state surcharge on enrollment in a health insurance planresults from differenceindifference linear probability model. **Please Note: Nothing contained in this blog post is to be construed as legal advice. If your company aims to reduce tobacco use among employees, one way it may consider doing this is by charging tobacco users more for their health insurance premiums.

Barbara J. Zabawa is the founder and president of the Center for Health and Wellness Law, LLC, a law firm dedicated to improving legal access and compliance for the health and wellness industries. Objective: Want updates on the latest lung health news, including COVID-19, research, inspiring stories and health information? Instead, the employer gave employees only two options: 1) dont use tobacco and avoid the surcharge; or. However, the interaction term between nonsurcharge state and current smoker was only statistically significant at P<.05 for nongroup insurance, which gives us confidence in the specifications presented in Table2 that excluded individuals with insurance through an employer or public program. Although third parties helped administer the tobacco cessation program for Macys, Macys had ultimate control of the wellness program, including: Because of these alleged violations, the DOL is asking the court for the following relief (in relation to the wellness program violations): Also in November 2021, a federal district court in Missouri certified a class action of 1500 casino workers who alleged, similar to the Macys case, that their employer violated ERISA with its tobacco surcharge. Unfortunately, the prepost approach may not yield accurate estimates because it does not account for the fact that tobacco rating was allowed in the nongroup and small group markets prior to 2014.

, If that is how employees feel, they may be compelled to complain to the EEOC that the companys wellness program violates the ADA. The ACA divides wellness program activities into 2 groups: participatory and health-contingent. and transmitted securely. The employer determined tobacco use status through an affidavit completed by each employee covered under the employer group health plan.

States that prohibit tobacco surcharges completely are California, Massachusetts, New Jersey, New York, Rhode Island, Vermont, and Washington, D.C. Connecticut also prohibits tobacco surcharges, but only for health plans sold in the states health insurance exchange (Access Health CT).

We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers.

WebTobacco cessation must be provided at no cost under most types of health insurance as of January 1, 2014. Tobacco Surcharge Policies and Instructions. The EX Program qualifies as a reasonable alternative standard. 10 This suggests that smokers living in nonsurcharge states might be more likely to have employer sponsored health insurance than smokers living in states that allow tobacco surcharges. This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states.

Participants overwhelmingly reported that cost of health insurance was a major reason for either not visiting their state's health insurance marketplace website or not purchasing a plan. September 29, 2021.

Data collection:

Respondents also listed tobacco surcharges as a major factor.

official website and that any information you provide is encrypted That is, it must have a reasonable chance of improving the health of, or preventing disease in, participating individuals, and it should not be overly burdensome. 64C increased to $3.51 per pack. 2

, Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. Arkansas limits it to 20%, and Kentucky limits it to 40%. Thank you!

sharing sensitive information, make sure youre on a federal The program must give individuals eligible for the tobacco cessation program the opportunity to qualify for the lower premium at least once per year. The participant is not expected to achieve a certain wellness goal, such as losing a certain amount of weight or having a certain blood pressure level. Results showing the impact of the size of tobacco surcharges are presented in Table4. Nonetheless, this study shows that lower surcharges were associated with higher enrollment in nongroup plans. 21 Pesko MF, Maclean JC, Kaplan CM, Hill SC. Employers who financially penalize tobacco users miss an opportunity to help them, which is why the ACA reasonable alternative and reasonable design requirements are so crucial in a successful tobacco cessation program. The plan must disclose in all plan materials the terms of a tobacco cessation program and the availability of a reasonable alternative standard to qualify for the lower premium (and, if applicable, the possibility of a waiver). 1 Select your location to view local American Lung Association events and news near you. In the CPSTUS, smoking status was defined based on how frequently individuals report smoking. Income eligibility for assistance under the affordable care act: technical memorandum on estimates for nonelderly adults.

Setting up a tobacco surcharge may seem straight forward but for it to be effective, you need to be strategic.

Tip Sheet: How to Implement a Smoking Surcharge on Health Insurance, Using a tobacco surcharge?

Instead, the notice materials stated employees would only avoid the tobacco surcharge on a prospective basis.

HHS Vulnerability Disclosure, Help Among those who would be able to purchase health insurance through the marketplaces but chose to remain uninsured, the tobacco surcharge was reported as a major factor in the decision.

Standard errors, clustered at the state level are shown in parentheses.
This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states. The extra money being saved by participation is impossible to pass up given their financial situation. Finally, we ran a model using a definition of tobacco use closer to the definition used for enrollment in the ACA, which includes the use of other noncigarette tobacco products. Kentucky Information The Potential and peril of health insurance tobacco surcharge programs: evidence from Georgias state employees health benefit plan, https://www.kff.org/other/stateindicator/individualmarketraterestrictionsnotapplicabletohipaaeligibleindividuals/, https://www.cms.gov/files/document/4120healthinsuranceexchanges2020openenrollmentreportfinal.pdf. Although federal regulations require that plans charge tobacco users no more than 50% higher premiums, several states have more strict regulations. Additionally, after limiting the sample to those most likely to benefit from the marketplace (individuals who did not have insurance through an employer or public program and who had incomes above 138% FPL), we found that the probability that a smoker was enrolled in a nongroup plan decreased by 8.6 percentage points (P=.02) relative to nonsmokers for every 10 percentage point increase in the size of the tobacco surcharge.



In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P<.01) for every 10 percentage point increase in the tobacco surcharge.

4 However, there were no significant effects for nonmarketplace nongroup insurance plans. Our results also show that the impact was largest in the exact insurance segments that were exposed to tobacco surcharges, increasing confidence that the policy has an effect on enrollment. Federal government websites often end in .gov or .mil. Each column is a separate regression, and the interaction term between surcharge state and current smoker shows the key differenceindifference coefficient.

In addition, there is large variation in tobacco surcharges even within states that allow surcharges since most insurers do not charge the maximum allowable surcharge.

Three states have set a maximum tobacco surcharge of less than 50%: Arkansas: 20% Colorado: 15% Kentucky: 40% Six states and DC have banned tobacco We found that the likelihood of having insurance among smokers was 4.0 percentage points (P=.02) lower in surcharge states, while Friedman and coauthors found that enrollment was 4.3 percentage points lower in states with medium sized surcharges, compared to states without surcharges, although their estimate was not statistically significant. So before implementing any tobacco surcharges, be sure to check if your state law also adds restrictions. As a result, if a tobacco cessation program offers an incentive to test for a chemical related to tobacco use, the program must be mindful of the ADA voluntary requirement. As of July 1, 2013, the excise tax imposed on cigarettes under M.G.L.

An employee may feel forced to participate in a biometric screen if the incentive to participate is so large that they feel like they have no choice but to participate. 13 FOIA Some call this difference in health insurance premium amounts a premium differential or a tobacco use surcharge.. We then asked respondents to select all reasons they did not enroll in a marketplace plan. 8600 Rockville Pike Moreover, the time commitment required for the reasonable alternative standard must be reasonable.

However, since theoretically tobacco surcharges should primarily affect the decision to purchase nongroup insurance, our preferred specification excluded individuals who had insurance either through an employer or a public program such as Medicare, Medicaid, or Military insurance.



stop using tobacco or

Eliminating tobacco surcharges or substantially limiting them is an option that state policy makers may consider in order to increase health insurance coverage among this particularly vulnerable population.

Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. 1 4.



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