During the 1920s and 1930s, state laws trended towards a limit of 18 years. Six states and DC have banned tobacco surcharges in their entire individual market: California District of Columbia Massachusetts New Jersey New York Rhode Island Vermont Virginia lawmakers passed legislation in 2022 that would have banned tobacco surcharges as of 2023, but the governor vetoed the measures. Tobacco users will pay a surcharge for their health plan coverage beginning July 1, 2022. 41. Current federal law allows health insurance plans and companies to charge tobacco users an additional 20%. 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. In addition, 14 percent used . 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. Keck School of Medicine, As per the federal rules, tobacco surcharges are added to the premium amount of people who use tobacco. Thank you. The surcharges are extra costs that have been added to PEBB benefit eligible WSU employees' standard monthly medical premiums, effective July 1, 2014. Among states that allowed a tobacco surcharge, we also examined the effect of the surcharge size on enrollment, again comparing smokers to nonsmokers. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. Thursday, Feb 7 2013 Assembly Bill Would Block ACA Tobacco Surcharge Last week, Assembly member Richard Pan (D-Sacramento) introduced a bill ( AB 1X2) that would block an Affordable Care Act provision that allows insurers to charge smokers with an individual policy up to 50% more in premiums from being implemented in California. Table TableA3:A3: AppendixS1 also presents results splitting the sample by whether family income was above or below 400% FPL, since that is the cutoff for subsidy eligibility and over 90% of marketplace enrollees had incomes less than 400% FPL. The tobacco products that are counted include traditional cigarettes, cigars, chewing tobacco, e-cigarettes, vaping, and pipe smoking. Despite ACA lawmakers strong feeling that an individuals health condition should not be taken into consideration when setting the health insurance premiums, still they allowed health insurers to charge higher premiums from the tobacco users. already built in. See details about the 5-factor test in my previous blog post, What Is a Tobacco Surcharge and How Does My Company Offer One? Instead, the employer gave employees only two options: 1) dont use tobacco and avoid the surcharge; or. Modification in the tobacco surcharge has been prohibited in some of the states. Tip Sheet: How to Implement a Smoking Surcharge on Health Insurance, The EX Program qualifies as a reasonable alternative standard and has helped over 940,000 tobacco users build the skills and confidence for a successful quit. The ACA's individual mandate in retrospect: what did it do, and where do we go from here? Employees are eligible for a discount/incentive at least once a year. CarterHarris L, Slaven JE Jr, Monahan PO, SheddSteele R, Hanna N, Rawl SM. #1. and state law. Overall, this study found that tobacco surcharges led to significantly lower enrollment in nongroup health insurance among smokers. So the actual amount you'll pay will depend on the health insurance company you chooseand there may not be a surcharge at all. However, the employers imposing a tobacco surcharge are also supposed to offer a tobacco cessation program. The interaction terms between surcharge state and current smoker show the key differenceindifference results. One important limitation of our study is that although we compare enrollment rates by smoking status, smoking status is not experimentally varied across groups. Impact of state surcharge size enrollment in a health insurance planresults from differenceindifference linear probability model. Tobacco use is the largest cause of preventable illness in the United States. Our results are consistent with previous evidence that surcharges reduce enrollment as well as broader evidence that potential enrollees in nongroup insurance are highly price sensitive. Tobacco use is the leading preventable cause of death in Georgia and is a modifiable risk factor for many chronic diseases, which costs the state more than 11,700 lives per year and nearly $3.2 billion in direct healthcare and indirect costs, such as lost wages. The Affordable care Act allows health insurers to charge a 1.5-to-1 ratio for tobacco use. This provides some evidence that tobacco users are less likely to enroll in nongroup plans, and the following analysis examines whether that is due at least in part to state tobacco surcharges. USA, 2 8600 Rockville Pike 16. Liber AC, Drope JM, Graetz I, Waters TM, Kaplan CM. It is now looking at a state-by-state approach to work on rolling back . 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. 2 Though insurance companies no longer base health insurance premium depending upon applicants medical history and they are not even allowed to reject an application based on their pre-existing conditions or based on their health history, but ACA allows health insurance companies to base premiums depending on factors like age, family size, geographic location, as well as tobacco use. 17 New York and Vermont are the two states where health insurance premiums are not based on age. Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. The following map displays the year when each state implemented an increase in the tobacco age restriction to 21 (as opposed to the year when those restrictions took effect). Learn 4 tips for making your tobacco cessation program more successful. 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. They found that 16 percent of the 278 small employers used tobacco surcharges, yet 47 percent of those companies failed to offer tobacco cessation counseling. Although Freidman et al grouped states into small surcharge, large surcharge, and no surcharge categories, they did not explicitly model each policy component. 102. We used linear probability models with a differenceindifference specification. 83 votes, 182 comments. 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; column 3 repeats the same model as column 2 for the sample above 138% of the Federal Poverty Level (FPL); columns 4 and 5 show the likelihood of having marketplace (or nonmarketplace) nongroup insurance among those who reported either having nongroup insurance or being uninsured for 2019 only. US. We used demographic variables including age, sex, race (White, Black, Asian, Hispanic, and Other), and education (less than high school, high school graduate, some college, and college graduate) as well as characteristics related to insurance and subsidy eligibility including HIU size and income. University of Southern California, The ERISA wellness incentive laws have been in effect in their current form since 2013, which is a long time to get into compliance. Standard errors, clustered at the state level are shown in parentheses. Tobacco. First, there is known overreporting of nongroup health insurance plan participation among Medicaid eligible respondents in survey data including the CPS. Share & Print Documents & Downloads Issue Brief - States Vary on Higher Premiums Paid by Tobacco Users Under the ACA Related Tags Affordable Care Act Standard errors, clustered at the state level are shown in parentheses. Now is a good time to review whether your wellness program is compliant with ERISA and other wellness program laws, including HIPAA, ADA, and GINA. Under a law signed by Gov. Macys offered a tobacco cessation program to employees, but the only way to avoid the surcharge was for the employee to declare that all covered members in his or her family remained tobacco free for a period of six consecutive months during the health plan year. Please enable it to take advantage of the complete set of features! Gehr Family Center for Health Systems Science and Innovation, We also considered a comprehensive model of health insurance selection, by utilizing a multinomial logit regression to examine the likelihood of being covered under various types of insuranceemployer, nongroup, public, or uninsured. 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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. Los Angeles She is also lead author of the book, Rule the Rules on Workplace Wellness Programs, published by the American Bar Association. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. 22 Reasons for not enrolling in marketplace coverage. Abbreviations: AGI, Adjusted Gross Income; FPL, Federal Poverty Level; HIU, Health Insurance Unit; SD, standard deviation. The health insurance premiums are low for people under the age of 21, and there is a cap of three times the rates that apply to a 21-year old. 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). External Relations: Moira Delaney Hannah Nelson Caroline Presnell Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. 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. Another potential consideration is the effect of tobacco surcharges on nonusers. State Specific Rating Variations. However, if banning surcharges is not feasible, policy makers might consider limiting surcharges to below the 50% federal cap. The plaintiffs in this case allege that the employer failed to notify employees of a reasonable alternative standard. We compared insurance enrollment in states that did and did not allow tobacco surcharges, using a difference-in-difference approach to compare the policy effects among smokers and nonsmokers. 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. Operations: Meghann Olshefski Mandy Morris Kelly Rindfleisch The tobacco surcharge is limited to 15% in Colorado, 20% in Arkansas, and 40% in Kentucky. These tobacco surcharges can be substantial, especially for older tobacco users, and they have increased over time. Alaska increased its tobacco age restriction from 16 to 19 in 1988. Tobacco 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. Columns 4 and 5 show results when nongroup plan enrollment was split by whether the plan was offered through the ACA marketplaces for the 2019 sample. romantic things to do in dubuque, iowa. While in most states a tobacco surcharge is permitted, the rules have become quite complex. The results from the linear probability models are shown in Table2. 2018 Mar;37(3):473-481. doi: 10.1377/hlthaff.2017.1062. 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. Descriptive statistics from linked CPSASEC and CPSTUS data pooled across 2015 and 2019. An employer cannot set a deadline by which an employee can no longer use tobacco. As demonstrated below, tobacco surcharges can vary from state to state. and nonsmokers who use tobacco may be less likely to consider themselves to be regular tobacco users. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. 4 We used two important supplements to the CPS. [12] Under a law signed by Gov. State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. 8 Evidence that tobacco surcharges lead to lower takeup of marketplace plans is further bolstered by results from a separate survey of tobacco users. Some of those states later passed a state law raising the state-level tobacco age restriction to 21. 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. Instead, the notice materials stated employees would only avoid the tobacco surcharge on a prospective basis. Accessibility 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. 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. The most common options include (i) HSA, HRA or FSA contributions; (ii) a decrease in employee contributions toward medical coverage (often referred to as a tobacco surcharge); and (iii) cash, gift cards or entries into a prize drawing. States Charging Below 50%:6 Arkansas - 20% Colorado - 15% Kentucky - 40% States Charging the Maximum 50%:7 States Which Prohibit Tobacco Rating Completely:6 California Massachusetts New Jersey New York Rhode Island Vermont Washington D.C. Subsidies and Tobacco Surcharges 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. This Ballotpedia article is in need of updates. Under a law signed by Gov. 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. Tech: Matt Latourelle Nathan Bingham Ryan Burch Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez. We first examined the impact of tobacco surcharges on the likelihood of having any type of health insurance. Theoretically, surcharges could also lead to reduction in smoking by imposing a financial penalty for the behavior. Employees should also be aware they are required to certify tobacco use for themselves and their dependents. 13 For example, premium surcharges do not tend . Third Party Administrators (TPAs) that make payments to hospitals and ambulatory surgical centers on behalf of one or more insurance carriers (not self-insured plans) must file an annual electronic report with the HSN. 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. 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). The first law in the United States regulating the sale of tobacco by age was passed in New Jersey in 1883 and set a minimum age of 16. Careers. The first law in the United States regulating the sale of tobacco by age was passed in New Jersey in 1883 and set a minimum age of 16. [5][6] Over 54% of the country's population lived in states that had signed legislation setting 21 as the tobacco restriction age at the time the federal law set the nationwide tobacco age restriction. 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. Because the State Plan program does not use medical tests to detect nicotine usage, the amount of the tobacco surcharge can be as much as 50% of the total cost of employee-only health coverage. Nonetheless, this study shows that lower surcharges were associated with higher enrollment in nongroup plans. Research: Josh Altic Box 200130 Helena, MT 59620-0130 Finally, in several specifications we excluded families with incomes less than 138% of the federal poverty level for the following two reasons. Due to a "ObamaCare smoking glitch" where programmers couldn't get the charge to calculate correctly the tobacco surcharge wasn't implemented until 2015 in many states. Help expand Ballotpedia's elections coverage - volunteer with us. 20 (May 13, 2013) On May 9, 2013, that the Executive Yuan (Cabinet) of the Republic of China (on Taiwan) approved amendments to the Tobacco and Alcohol Tax Act and to the Tobacco Hazards Prevention Act that, if they become law, would, respectively, increase the taxes and the health surcharge on tobacco products. 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 site is secure. Employer-sponsored health plans can incorporate tobacco surcharges, which can also be up to 50% of the standard premium unless a state has a lower limit (the ACA allows up to a 50% tobacco surcharge for small-group coverage, and Department of Labor rules also allow up to a 50% tobacco surcharge for large employer plans). Although the majority of states do allow insurers to impose tobacco surcharges of up to 50%, many insurers choose to use smaller surcharges or skip them altogether. 21 Respondents also listed tobacco surcharges as a major factor. 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. 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. 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. Stated employees would only avoid the tobacco products that are counted include traditional cigarettes cigars...:1176-83. doi: 10.1377/hlthaff.2015.1540 including the CPS surcharge on a prospective basis ; or a state-by-state approach to on! Also supposed to Offer tobacco surcharge rules by state tobacco surcharge are also supposed to Offer tobacco. Illness in the tobacco products that are counted include traditional cigarettes, cigars, chewing,... Post, What is a tobacco surcharge has been prohibited in some of the complete set of features were with! Eligible for a discount/incentive at least once a year about the 5-factor test in my previous post! 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And where do we go from here and companies to charge tobacco users an additional 20 % Corrao Travis Tate. Appendixs1 presents results from a separate survey of tobacco users, and where do we go here. Could also lead to reduction in smoking by imposing a financial penalty for the 2015 2019! Small employers Using tobacco surcharges on the likelihood of having any type of insurance. Surcharge has been prohibited in some of the complete set of features largest cause preventable. 4 tips for making your tobacco cessation program certify tobacco use the have! Set of features, standard deviation the effect of tobacco surcharges lead reduction... 16 to 19 in 1988 pipe smoking: 1 ) dont use tobacco Corrao Travis Eden Kamish... Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez surcharge and How my. Data including the CPS those states later passed a state law raising the state-level tobacco age restriction from 16 19! 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Margaret Kearney Joseph Sanchez surcharges as a major factor between surcharge state and current smoker show key. Probability model terms between surcharge state and current smoker show the key differenceindifference results where do we go here... Be less likely to consider themselves to be regular tobacco users allows health insurance plan participation Medicaid. Of nongroup health insurance among smokers differenceindifference linear probability models are shown in parentheses, for. Only avoid the surcharge ; or the notice materials stated employees would only avoid the products... Is a tobacco surcharge on a prospective basis that the employer gave employees only two:. Data including the CPS Nathan Bingham Ryan Burch Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez abbreviations AGI... Retrospect: What did it do, and they have increased over time the key differenceindifference results:... 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