In addition, the complaint alleges that even when the employer offered a reasonable alternative standard (i.e., a smoking cessation program), the employer did not provide employees the full reward once they completed the program. Respondents also listed tobacco surcharges as a major factor. Public insurance includes Medicare, Medicaid, VA, CHAMPUS, Tricare, and Indian Health Service. sharing sensitive information, make sure youre on a federal 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. Standard errors, clustered at the state level are shown in parentheses. 2 For the purposes of this study, we limited the sample to uninsured individuals (N=519). Each column is a separate regression, and the interaction term between surcharge state and current smoker shows the key differenceindifference coefficient. 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. This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. For purposes of the premium surcharge, "tobacco use" is defined as: . Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. This allows employees to avoid the surcharge by participating in the cessation program. So the actual amount you'll pay will depend on the health insurance company you chooseand there may not be a surcharge at all. This table presents estimates from a multinomial logit regression model, comparing the likelihood of being in one of four insurance categoriesuninsured (reference group), nongroup, employer, or public. HHS Vulnerability Disclosure, Help County populations were pulled from the 2014 and 2018 American Community Survey annual county level estimates and aggregated up to the rating area level. Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. Click here to contact us for media inquiries, and please donate here to support our continued expansion. 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. 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. 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. We linked data from two components of the Current Population Survey-the 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. Thus, perhaps somewhat counterintuitively, eliminating or limiting surcharges could potentially lead to an increase in quitting. Tobacco use is the largest cause of preventable illness in the United States. After calculating AGI, we excluded adults over 65 since they would likely be covered by Medicare. 16. 13 At incomes over 138% FPL, insurance eligibility is substantively similar across states. Data collection: , Health Aff (Millwood). **Please Note: Nothing contained in this blog post is to be construed as legal advice. Tech: Matt Latourelle Nathan Bingham Ryan Burch Kirsten Corrao Travis Eden Tate Kamish Margaret Kearney Joseph Sanchez. 7 State agency staff must ensure the tobacco user premium differential is deducted from employees' net pay when applicable. 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. , Instead, the notice materials stated employees would only avoid the tobacco surcharge on a prospective basis. The ERISA wellness incentive laws have been in effect in their current form since 2013, which is a long time to get into compliance. 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 a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). These people are also less likely to receive timely medical treatment at the time when they will need it. 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. Six States (California, New York, New Jersey, Massachusetts, Rhode Island, and Vermont) plus the District of Columbia have outlawed tobacco surcharges altogether, while Arkansas, Colorado, and Kentucky have limited tobacco surcharges to levels less than 50%. If the program uses a medical test to detect nicotine or tobacco use, it also must comply with the ADA's rules for voluntary wellness plans. 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. Critics of surcharge policies point to data from other health-contingent premium programs showing that they fail to change individuals' behavior. Massachusetts has many laws that govern tobacco: Tobacco excise taxes. The federal law gives insurers the right to add up to 50 percent to the cost of individual health care coverage. 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. By 1920, 46 states had implemented an age limit for tobacco sales, of which 14 set the limit at 21. State of Montana Health Care & Benefits Division 100 North Park Ave ., Suite 320 P.O. The practice of implementing a surcharge to recoup the costs of credit card processing fees was illegal across the country for several decades. [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. marketing materials using the information you provide. Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. 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. Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. Geographic Location The costs of health insurance premiums are not the same in every zip code, and vary from one area to another. 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. surcharge cannot exceed 50 percent of the total cost of health coverage. 8 Setting up a tobacco surcharge may seem straight forward but for it to be effective, you need to be strategic. Rate: 35% of the wholesale purchase price; Both cigarettes and other tobacco products are subject to the 4.5% state sales tax rate plus the general municipal sales tax rates when sold at retail. State government tax collections by source, State spending by function as a percent of total expenditures, Financial regulation in the United States, Education statistics in the United States. Clipboard, Search History, and several other advanced features are temporarily unavailable. The functionality is limited to basic scrolling. 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. Consistent with the family income calculation for health insurance qualification, we excluded income under $12200 for dependents. 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. 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. Table1 compares sample characteristics across insurance type. In this paper, we examined how differences in state tobacco surcharge policy influenced health insurance enrollment choices among smokers. 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. 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). Keywords: The state lowered the age of majority, which also served as a tobacco age restriction at the time, from 21 to 19 in 1976. Although state tobacco rating rules typically do not apply to large employers, it is possible that there are spillover effects. 15 26 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 surcharges are extra costs that have been added to PEBB benefit eligible WSU employees' standard monthly medical premiums, effective July 1, 2014. , Qualtrics maintains a nationally representative network of individuals who have previously agreed to participate in survey research. Disclaimer, National Library of Medicine Marketing materials may be provided via The program may include a tobacco surcharge to help motivate employees. 9 Employees should also be aware they are required to certify tobacco use for themselves and their dependents. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. The https:// ensures that you are connecting to the 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. Reasons for not enrolling in marketplace coverage. 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. Age The health insurance premiums are based on an individuals age, as older people are charged higher premiums compared to younger people. 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. Family Size The health insurance premiums of a family is determined based on every person in the family. Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation. 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. The ePub format uses eBook readers, which have several "ease of reading" features If people avoid health insurance simply because they cant afford it, then they will also not able to access the coverage for the free tobacco cessation that is included with ACA-compliant health plans. 14 Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P=.01). An official website of the United States government. You may notice problems with Additionally, the elimination of the individual mandate has led to a decrease in enrollment, Youth access to tobacco law-RCW 70.155: Prohibits the sale and distribution of tobacco products to minors. Los Angeles 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. Tobacco products are mostly used by lower-income Americans than higher-income Americans. CA, Though the Affordable Care Act has included a provision to allow insurers to charge higher premiums from tobacco users but has not specified what constitutes tobacco use. The nationwide average pre-subsidy premium in 2020 is about $576 per month for health plans sold in the exchange. Tobacco surcharge has also been prohibited in Connecticut but only for plans that are sold through the states health insurance exchange. 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. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. 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. 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. While in most states a tobacco surcharge is permitted, the rules have become quite complex. , Most states, however, follow the federal law and allow insurers to impose tobacco surcharges of up to 50% but employer wellness programs must follow certain rules for those surcharges to be legal. Accessibility 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. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. Among those who reported being uninsured, we asked respondents to provide the main reason they did not either visit a marketplace website or enroll in a marketplace plan from a list of options. 2 CarterHarris L, Slaven JE Jr, Monahan PO, SheddSteele R, Hanna N, Rawl SM. Loyola Marymount University, Health Serv Res. Box 200130 Helena, MT 59620-0130 The plaintiffs are seeking a refund of all the tobacco surcharges collected by the employer since 2016. 18. 20 There has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge on health insurance. Compared to those with insurance, uninsured individuals tended to be younger, have smaller family sizes, lower levels of family income and education, and they are more likely to be male and nonwhite. 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. Credit Card Surcharge Laws by State: A Guide for AEC Pros. 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. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. Yep, among other crappy changes we just found out to our insurance, starting in 2014, as supervisors employed at UPS, we will have to pay $150 a month pre-tax if we or a spouse who is also enrolled in United Healthcare through UPS uses: tobacco products such as: cigarettes, cigars, pipe tobacco, chewing or dipping . Health Aff (Millwood). Minors are prohibited from buying alternative nicotine products, including e-cigarettes.6 Establishments are required to post signs stating that sales to minors are prohibited.6 Local tobacco laws Tobacco Surcharges - Legal Rules Tobacco surcharge may also be incorporated in the employer-sponsored health plans that can increase the standard premium by up to 50% unless a state has implemented a lower tobacco surcharge. FOIA 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). 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. The DOL alleged that Macys tobacco cessation program violated the ERISA wellness program incentive rules for numerous reasons. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. However, it is the case only if they dont use tobacco but if they do use tobacco then the tobacco surcharge may result in unaffordable health insurance premiums for these people. Please email us if you would like to suggest a revision. Health Aff (Millwood). Please enable it to take advantage of the complete set of features! Nineteen of those states set the tobacco age restriction to 21 before the federal law took effect, while the other 19 did so after the federal law took effect. The .gov means its official. Our insurance expert will call you soon. Conclusions: In these years, adult members of households included in the basic monthly CPS were surveyed in June of the first year (2014 and 2018) and January and May of the second year (2015 and 2019). 12 First, there is known overreporting of nongroup health insurance plan participation among Medicaid eligible respondents in survey data including the CPS. the display of certain parts of an article in other eReaders. Employees at several companies are pushing back on employer wellness programs that require higher health insurance premiums for tobacco users. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. , Providing adequate notice about the reasonable alternative standard is also mandatory. University of Southern California, 7 Ballotpedia features 393,617 encyclopedic articles written and curated by our professional staff of editors, writers, and researchers. 10 Joint Acknowledgment/Disclosure Statement: This study was funded by a grant from the American Cancer Society (RSGI1723401CPHPS). Actual causes of death in the United States, 2000. Come Jan. 1, smoking is one of the few allowable factors . Beginning January 1, 2014 health insurance plans and employers will be able to charge up to 50% more. The inclusion of state fixed effects holds constant any state specific factors that might affect differential insurance enrollment choices between smokers and nonsmokers. An employer cannot set a deadline by which an employee can no longer use tobacco. All regressions are weighted using the appropriate weights from the Current Population Survey. 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. and transmitted securely. 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. 1 PMC 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. Additionally, the fact that the inclusion of state fixed effects in our model of the impact of surcharge size produced nearly identical results to the same model without state fixed effects gives us confidence that this identification assumption holds. Ten Democratic governors and eight Republican governors signed increases in tobacco age restrictions during this time.[3]. Smokers could find themselves burned by the Affordable Care Act. Income eligibility for assistance under the affordable care act: technical memorandum on estimates for nonelderly adults. Whenever a violation is sustained against you for a sale of tobacco or other age-restricted product to an individual under 21 years of age, besides imposing the payments of a fine and a surcharge, you will be assigned two points, unless you demonstrate that at the time of the sale, the seller possessed a valid certificate from a State certified . 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. Pesko MF, Maclean JC, Kaplan CM, Hill SC. We coded respondents as current smokers if they reported now smoking cigarettes either every day or some days. This definition is slightly different from the definition used to apply the tobacco surcharge, which is the use of tobacco products four or more times, on average, per week within the past six months. We used the narrower definition, considering only cigarette smokers because cigarette smokers make up most of the population of every day tobacco users Objective: 2023 All rights reserved to InsureMeNow | Terms & Conditions | Privacy Policy. The outcome variable represents four categories of insurance typeuninsured (omitted), nongroup, employer, and public. A number of states have passed laws prohibiting the rate increase for tobacco users or allowing a rate increase of less than 50%. However, thanks to a class action lawsuit in 2013, a large number of states began permitting the practice . Benefits Insight. State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. tobacco surcharge rules by state. Although federal regulations require that plans charge tobacco users no more than 50% higher premiums, several states have more strict regulations. Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. Colorado limits the tobacco surcharge to 15%. Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. We also calculated state policy variables to adjust for differences that may be correlated with tobacco surcharge policy and health insurance enrollment including whether the state was a Medicaid expansion state and the use of a statebased marketplace. States Vary on Higher Premiums Paid by Tobacco Users Under the ACA Kansas insurers applying up to 44 percent surcharge for tobacco users in 2015 11 Min Read Sep 09, 2015 By Linda J. Sheppard, J.D. 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). As of July 1, 2013, the excise tax imposed on cigarettes under M.G.L. To avoid the surcharge by participating in the cessation program * please Note: Nothing contained this... Coded respondents as current smokers if they reported now smoking cigarettes either every day or some days Kirsten Travis... 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