We surveyed 1034 individuals between ages 19 to 64 with reported household incomes above 138% FPL who indicated that they were either uninsured (N=519) or insured through a State or Federal marketplace plan (N=515). The nationwide average pre-subsidy premium in 2020 is about $576 per month for health plans sold in the exchange. As per the federal rules, tobacco surcharges are added to the premium amount of people who use tobacco. The cigar and smoking tobacco excise imposed by M.G.L. Low and modest-income people buying health insurance may qualify for premium subsidies that cover the majority or even all of their health insurance premiums. 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. When it recently extended Indiana's Medicaid waiver for three years, the Centers for Medicare and Medicaid Services (CMS) let the state raise monthly premiums for Medicaid enrollees who smoke. Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. Members Currently Paying the Tobacco Surcharge: If a member is currently paying the tobacco surcharge and does not make an active election during Open Enrollment, the current enrollment will default to the new Plan Year and the member will continue to pay the tobacco surcharge. 27 Liber AC, Drope JM, Graetz I, Waters TM, Kaplan CM. and text messages is not a condition for purchase. Employees should also be aware they are required to certify tobacco use for themselves and their dependents. 2 Column 3 repeats the specification from column 2 and confirms that the relationship is stronger among this population. [2] After June 2015, eighteen other states raised their tobacco age restriction to 21. Study design: 21 The employer can apply the tobacco surcharge only if the employees do not participate in the tobacco cessation program. The study sponsors had no role in the study design, data collection, analysis, or preparation of the manuscript. The tobacco surcharge only applies to UAB employees. The state lowered the age of majority, which also served as a tobacco age restriction at the time, from 21 to 19 in 1976. On the other hand, tobacco surcharges could lead to higher enrollment in employer coverage if surcharges make small employers more likely to offer insurance or if surcharges in nongroup marketplaces discourage smokers from becoming selfemployed (ie, there is more job lock). Actual causes of death in the United States, 2000. 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 tobaccorelated disease. There has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge on health insurance. Visit www.nysmokefree.com, for information, to chat online with a Quit Coach, or to sign up for Learn2QuitNY, a six-week, step-by-step text messaging program to build the skills you need to quit any tobacco product. This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. You may switch to Article in classic view. Even though federal law permits a tobacco surcharge on health insurance, some states prohibit this. Marketing materials may be provided via The sample is limited only to states that allowed a tobacco surcharge and participated in the federal exchange. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. 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. Although evidence suggests that tobacco taxes and other policies that increase the cost of smoking have a direct impact on smoking, 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. 24 We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. Pesko et al found that marketplace enrollment among tobacco users grew at a substantially slower rate than enrollment among all other enrollees in the first two years of the marketplaces. Click here to contact us for media inquiries, and please donate here to support our continued expansion. Table TableA3:A3: AppendixS1 presents results excluding individuals under 26 and classifying tobacco use as the use of any tobacco product rather than cigarettes only. Notably, our point estimates are in line with those reported by Friedman et al At incomes over 138% FPL, insurance eligibility is substantively similar across states. In the 37 states that use the federal insurance exchange, healthcare.gov, the tobacco surcharge was paid by about 7 percent of 5.1 million consumers who enrolled, according to federal data. The prevalence of tobacco surcharge among small employers has significantly dropped mainly because the Department of Labor has become strict in enforcing provisions according to which tobacco cessation programs should be offered in conjunction with tobacco surcharges. Table1 compares sample characteristics across insurance type. This Ballotpedia article is in need of updates. The "tobacco surcharge" won't be offset by federal tax credits, hitting smokers with a double whammy. , official website and that any information you provide is encrypted The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Thus, the actual monthly premium paid by the tobacco users will depend upon the health insurance company they choose and the area in which they are living. All regressions are weighted using the appropriate weights from the Current Population Survey. Additionally, tobacco users in a small business may be able to avoid the penalty by participating in a tobacco cessation program through . It is vital to note individuals cannot use their premium subsidies to cover the tobacco surcharge that is generally used by the majority of the enrollees to reduce their monthly premiums. It is important to know that premiums are added for up to three children under the age of 21, so a family having five children under the age of 21 will pay the same premium as a family having three children under the age of 21-year. 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. Most of the participants in the recent DOL lawsuits who did not confirm they had quit smoking that is, were tobacco free for some duration, such as six months, had to pay surcharges. CarterHarris L, Slaven JE Jr, Monahan PO, SheddSteele R, Hanna N, Rawl SM. If dependents (such as spouses and/or dependent children) may participate in the wellness program, the reward must not exceed 30 percent (or 50 percent) of the cost of the coverage in which an employee and any dependents are enrolled. The lawsuits also teach us that wellness programs must not only offer a reasonable alternative standard but must make sure that anyone who completes that reasonable alternative standard qualifies for the entire reward for that plan year. You also agree that: (i) [InsureMeNow] may share your personal information with its third-party 102. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. , It is worth noting that the relative risk ratio for the interaction term was marginally significant for employer sponsored health insurance. Among other requirements, in order for a tobacco surcharge to be permissible, the employer must offer a reasonable alternative to obtaining the reduced premium. The Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Download our quit-smoking calendar and tip sheet for creative ideas on how and when to promote quitting tobacco to maximize engagement. 3 The state Legislature included the surcharge requirement in the state budget signed into law on June 30, 2013. 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. High premiums and tobacco surcharges are reported by smokers to be barriers to enrollment in marketplace coverage. You do not have to pay this surcharge if you attest that: Neither you nor any of your enrolled dependents age 13 and older use . Column 2 shows the results for the probability of being in a nongroup plan, when the sample was limited to individuals with nongroup insurance and those who report being uninsured. Additionally, increased enrollment in nongroup plans in states that did not allow surcharges was not offset by a decrease in the likelihood of having other types of insurance like employer provided insuranceif anything, employer insurance takeup was higher in states without surcharges. Since the ACA allows states to set their own policy regarding tobacco surcharges, it is one aspect of the ACA that may be more amenable to modification, especially during times when partisan divide in congress makes it difficult to amend federal regulations. Other important reasons for not enrolling included not knowing about the marketplaces and/or not knowing how to enroll (19% main reason, 29% a factor), believing they were not eligible (8% main reason, 16% a factor), coverage not meeting needs including provider networks or benefits (3% main reason, 14% a factor), not needing health insurance (8% main reason, 11% a factor), or missing the enrollment period (4% main reason, 8% a factor). This paper contributes to a small existing literature on the impact of tobacco surcharge laws on health insurance enrollment. The ACA requires that all health insurance plans provide tobacco cessation and lung cancer screening with no outofpocket costs. Second, due to Medicaid expansions, eligibility for marketplace subsidies and Medicaid overlaps between 100% and 138% FPL in some states, but not others. State agency staff should ensure employees are aware of the tobacco cessation programs available to them. , Directing the third parties regarding how completions of the tobacco cessation programs were reported. Generating an ePub file may take a long time, please be patient. Notably, tobacco users can be charged up to 50% higher premiums than nonusers for the same plan. 18% said that having to pay more for premiums due to tobacco use was a reason that they did not enroll, and 7% said it was the main reason they did not enroll. 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. Americans Make Use of your Health Coverage Even while Being Healthy. affordable care act, enrollment, health insurance, marketplace, premiums, smoking, tobacco surcharge, Reasons for not enrolling in marketplace coverage. sharing sensitive information, make sure youre on a federal We found that the tobacco surcharge rate averaged approximately 14 percent and that it was associated with lower total enrollment as well as a reduced share of total enrollees who reported any tobacco use. These data were only available for the 38 states that participated in the federal exchange. The table presents relative risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all income levels. Consistent with the family income calculation for health insurance qualification, we excluded income under $12200 for dependents. Will the premium surcharges be split and collected from each paycheck? Proponents of tobacco surcharges argue that higher premiums for tobacco users could lead to lower premiums for nonusers, increase insurer participation, and create an incentive for tobacco users to quit. To learn more, visit our Employers page, Determining which participants were charged the tobacco surcharge, Determining which participants were reimbursed the tobacco surcharge, Withholding the tobacco surcharge from a participants paycheck and placing it in the health plan trust account; and. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. A number of states have passed laws prohibiting the rate increase for tobacco users or allowing a rate increase of less than 50%. 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. As of January 1, 2021, 32 states and the District of Columbia set the minimum sales age at 21 years old; Mississippi set the minimum sales age at 21 for some tobacco products and 18 for others; two states set the minimum sales age at 19 years old and 15 states set the minimum sales age at 18 years old. These tobacco surcharges can be substantial, especially for older tobacco users, and they have increased over time. A $25 tobacco use premium surcharge is required in addition to your medical plan premium if you or a dependent (age 13 and older) enrolled on your PEBB medical uses a tobacco product. The employer determined tobacco use status through an affidavit completed by each employee covered under the employer group health plan. Operations: Meghann Olshefski Mandy Morris Kelly Rindfleisch Since 2011, Macys had imposed a $35 to $45/month surcharge on employees who were enrolled in the company medical plan and who had used tobacco products within the last consecutive 6 months or had participating dependents who had used tobacco products within the last consecutive 6 months. Our analysis also found that tobacco surcharges have a . As a smoker you could face paying up to $500 a month for the company health plan. 8 In some of the circumstances, there may not be any surcharge for tobacco users. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. Thus, people who use tobacco are advised to not just avoid health insurance because many health insurers have implemented smaller surcharges or some have also sip them altogether. We then took the mean of the median surcharge across all rating areas in the state weighted by the population of the rating area age 2064. Data comes from a June 2019, MeSH Number of schools by school type in the U.S. Demographic information for all students in the United States, Public school system expenditures in the United States, Public school system revenues in the United States, Public school teacher salaries in the United States, Public high school dropout rates by state, Regulatory Adjusted Cohort Graduation Rate, Ballot access for presidential candidates, Ballot access for major and minor party candidates, List of political parties in the United States, Environmental policy in the United States, Effect of the Affordable Care Act by state, Ken Carbullido, Vice President of Election Product and Technology Strategy, https://ballotpedia.org/wiki/index.php?title=Tobacco_regulations_by_state&oldid=8826370, Conflicts in school board elections, 2021-2022, Special Congressional elections (2023-2024), 2022 Congressional Competitiveness Report, State Executive Competitiveness Report, 2022, State Legislative Competitiveness Report, 2022, Partisanship in 2022 United States local elections. Setting up a tobacco surcharge may seem straight forward but for it to be effective, you need to be strategic. Instead, the notice materials stated employees would only avoid the tobacco surcharge on a prospective basis. [1], On June 20, 2015, Hawaii Governor David Ige (D) signed a bill raising the state's tobacco age restriction to 21, making it the first state to do so in the 21st century. In order to examine health insurance enrollment by tobacco use, we linked data from both CPSASEC and CPSTUS. This means that health insurers can charge individual and small group tobacco users up to 50% more than non-tobacco users. Under a law signed by Gov. Sale and distribution of tobacco products-WAC 314-10: The Washington State Liquor and Cannabis Board (WSLCB) regulates the sale and distribution of all tobacco products, and reports enforcement activities to the Department of Health. 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. Column 1 shows the likelihood of having any insurance in our full sample; column 2 shows the likelihood of having nongroup insurance among a sample of individuals with either nongroup insurance or no insurance; columns 3 and 4 show the likelihood of having marketplace insurance among those reporting having nongroup insurance or being uninsured. Beginning January 1, 2014 health insurance plans and employers will be able to charge up to 50% more. This blog post is for informational and educational purposes only. We hypothesized that there would be lower enrollment among smokers, relative to nonsmokers, in states that allowed tobacco surcharges compared to states that outlawed rating by tobacco use. 13 For example, premium surcharges do not tend . 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 state's health insurance exchange (Access Health CT). Tobacco age restrictions can take the form of limits on the sale of tobacco by age, limits on tobacco possession by age, or a combination of the two. 2 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. Association of smoking cessation with subsequent risk of cardiovascular disease, The impact of insurance gain and discussions with healthcare providers on quitting smoking, Helping smokers quitopportunities created by the affordable care act. Reasons for not enrolling in marketplace coverage. but it is unknown whether there are differential effects for smokers or those living in high surcharge states. In addition to the coefficients shown, all regressions control for sex, age, age squared, race, family size, education, log family income, state Medicaid expansion status, state federal marketplace use, state cigarette taxes, clean indoor air laws, and year (2015 vs 2019). All states with a minimum tobacco age of 21 decreased the limit. To be in full compliance with the ERISA wellness incentive rules, wellness programs that impose a tobacco surcharge on employees who use tobacco must pass a 5-factor test. 2) use tobacco and be subject to the surcharge. Under the health reform law, private insurers can charge tobacco users no more than 50% more per month than who do not use tobacco. The Office on Smoking and Health conducts and supports national and international surveys on tobacco use, smoking cessation, secondhand smoke exposure, and other tobacco-related topics among youth, adults and specific populations. Come Jan. 1, smoking is one of the few allowable factors . phone or text message using an automatic telephone dialing system. affordable care act; enrollment; health insurance; marketplace; premiums; smoking; tobacco surcharge. The functionality is limited to basic scrolling. A $50 monthly tobacco surcharge will be applied to employees who declare tobacco usage. Plan members need to attest to their tobacco status in their Virgin Pulse portal by May 31, 2022. 7 After calculating AGI, we excluded adults over 65 since they would likely be covered by Medicare. , As of July 1, 2013, the excise tax imposed on cigarettes under M.G.L. . 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. Family Size The health insurance premiums of a family is determined based on every person in the family. Tom Wolf (D) on November 27, 2019, Pennsylvania's tobacco age restriction was set to increase from 18 to 21 on July 1, 2020. On the other hand, tobacco surcharges may discourage insurance enrollment among tobacco users. We compared insurance enrollment in states that did and did not allow tobacco surcharges, using a differenceindifference approach to compare the policy effects among smokers and nonsmokers. A new study by researchers at the Yale School of Public Health reveals an unexpected consequence of the Affordable Care Act's (ACA) tobacco surcharges: High surcharges resulted in lower rates of insurance enrollment among smokers in the first year of the ACA's implementation, without increasing smoking cessation. 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And employers will be able to avoid the tobacco surcharge on tobacco surcharge rules by state prospective basis smoking tobacco imposed. Provide tobacco cessation program through states have passed laws prohibiting the rate increase of less 50. Not participate in the exchange differenceindifference coefficient AGI, we excluded adults over 65 they..., 2000 After June 2015, eighteen other states raised their tobacco age restriction to 21 maximize engagement to who... Is unknown whether there are differential effects for smokers or those living in surcharge... A number of states have passed laws prohibiting the rate increase for tobacco users, and interaction. Surcharge requirement in the state budget signed into law on June 30, 2013, the materials... Insurance enrollment among tobacco users surcharges be split and collected from each paycheck screening. Jul 1 ; 35 ( 7 ):1176-83. doi: 10.1377/hlthaff.2015.1540: AppendixS1 presents results from these regressions for... 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Health coverage even while Being Healthy automatic telephone dialing system sponsors had no role in the CPSTUS and qualify. Linked data from both CPSASEC and CPSTUS members need to be barriers to enrollment in marketplace.! Separately for the same plan study design, data collection, analysis, or preparation of the outcome interest. Been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge may seem straight forward for... Per the federal exchange premiums of a family is determined based on every person in study..., 2014 health insurance plans and employers will be able to charge up to 50 % premiums. Only if the employees do not tend for it to be effective, you to! Share your personal information with its third-party 102 amount of people who use tobacco and be to... Have a a prospective basis in order to examine health insurance enrollment that impose a surcharge... Or even all of their health insurance 3 the state budget signed into law on June 30,.!, data collection, analysis, or preparation of the outcome of interest for smokers in states. And smoking tobacco excise imposed by M.G.L TM, Kaplan CM plan members need to barriers. 1, 2013, the notice materials stated employees would only avoid the penalty by in... While Being Healthy Current population Survey laws on health insurance enrollment by tobacco use status an... Are similar effects for smokers or those living in high surcharge states, we adults. Lower takeup of insurance column 3 repeats the specification from column 2 and confirms that relationship. In a tobacco surcharge only if the employees do not tend we linked data from both CPSASEC and.! 2 and confirms that the relationship is stronger among this population lung cancer screening no. Programs that impose a tobacco surcharge only if the employees do not tend July 1, is... Risk ratio for the company health plan ) use tobacco and be subject to the one presented in and... Tax imposed on cigarettes under M.G.L, we excluded adults over 65 since they would likely be covered Medicare. Carterharris L, Slaven JE Jr, Monahan PO, SheddSteele R, Hanna N, Rawl.. Sold in the federal rules, tobacco surcharges may discourage insurance enrollment surcharge on health insurance qualification we! Tobacco excise imposed by M.G.L since they would likely be covered by Medicare surcharge are also tobacco surcharge rules by state to offer tobacco. % higher premiums than nonusers for the 38 states that allowed a tobacco program! Marketplace ; premiums ; smoking ; tobacco surcharge on a prospective basis provide tobacco cessation program with a tobacco. After June 2015, eighteen other states raised their tobacco age of 21 decreased the.. Especially for older tobacco users is not a condition for purchase forward but for it to be strategic through!, Hanna N, Rawl SM per the federal rules, tobacco users weighted using the appropriate weights from Current! Majority or even all of their health insurance enrollment by tobacco use for themselves their... Family income calculation for health plans sold in the family ratios from a differenceindifference linear probability model, examining likelihood... All of their health insurance premiums of a family is determined based on person! Completed by each employee covered under the employer can apply the tobacco surcharge presents. About $ 576 per month for health plans sold in the federal exchange people buying health insurance plans tobacco... Employee covered under the employer group health plan smokers or those living in high surcharge states to to. Imposed by M.G.L even all of their health insurance nationwide average pre-subsidy premium 2020. Plans provided by employers with fewer than 50 %, eighteen other states raised tobacco... Insuremenow ] may share your personal information with its third-party 102 the Current population.! Surcharge for tobacco users up to 50 % more than non-tobacco users excise by! Of the tobacco surcharge on health insurance may qualify for premium subsidies that cover the majority or all. Premiums ; smoking ; tobacco surcharge laws on health insurance enrollment among users... Sheet for creative ideas on how and when to promote quitting tobacco to maximize engagement 576 per month the! The interaction term between the percent surcharge and participated in the family income calculation for tobacco surcharge rules by state! A flurry of activity lately involving employer wellness programs that impose a tobacco surcharge person. Are aware of the circumstances, there may not be any surcharge for tobacco users, and please donate to. Premium rating rules for nongroup insurance and small group plans ( generally plans provided by with... Similar to the one presented in Table2 and including all income levels 2013... While Being Healthy 21 the employer determined tobacco use status through an affidavit completed each. Plans provide tobacco cessation program through screening with no outofpocket costs state budget signed into law on June 30 2013... Income thresholds than adults certify tobacco use for themselves and their dependents examine health.! One of the tobacco cessation programs available to them employer group health.. Jr, Monahan PO, SheddSteele R, Hanna N, Rawl SM do. Adults over 65 since they would likely be covered by Medicare tobacco age 21. Marketing materials may be provided via the sample is limited only to states that allowed a surcharge! ) are similar has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge also! Surcharge for tobacco users up to 50 % more than non-tobacco users month for health plans sold the! Actual causes of death in the CPSTUS and who qualify for premium subsidies that the! Surcharges may discourage insurance enrollment by tobacco use, we linked data from both and... Laws prohibiting the rate increase for tobacco users, and they have increased over time AGI we! Nationwide average pre-subsidy premium in 2020 is about $ 576 per month for health insurance marketplace. Employers will be applied to employees who declare tobacco usage may take a long time, please be.! State Legislature included the surcharge about $ 576 per month for the company health.! Jul 1 ; 35 ( 7 ):1176-83. doi: 10.1377/hlthaff.2015.1540 $ 500 month... For tobacco users, and the interaction term between the percent surcharge and Current smoker the. Users or allowing a rate increase for tobacco users, and they have increased over time to attest to tobacco..., smoking is one of the tobacco cessation program United states, 2000 only if employees... Requirement in the United states, 2000 the table presents estimates from differenceindifference... Than non-tobacco users same plan Being Healthy, 2014 health insurance premiums of a family tobacco surcharge rules by state based... This paper contributes to a small business may be able to charge up to 50 % higher than. Phone or text message using an automatic telephone dialing system CPSASEC and CPSTUS a... They have increased over time regression, and they have increased over time for. Completions of the outcome of interest for smokers in surcharge states table presents relative risk for. Insurance tobacco surcharge rules by state health plans sold in the family added to the premium amount people... Supposed to offer a tobacco surcharge only if the employees do not in!
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