The ACA requires that all health insurance plans provide tobacco cessation and lung cancer screening with no outofpocket costs. In order to focus on health insurance coverage among individuals most likely to be affected by tobacco surcharges, we made several sample exclusions. Please email us if you would like to suggest a revision. All regressions are weighted using the appropriate weights from the Current Population Survey. Among the uninsured, respondents were asked to provide the main reason why they did not enroll in a marketplace plan from a list of options and then asked to check all reasons they did not enroll[Color figure can be viewed at. 11 Tobacco surcharges on 2015 health insurance plans sold in federally facilitated marketplaces: variations by age and geography and implications for health equity, Marketplace premiums rise faster for tobacco users because of subsidy design, Putting policy theory to work: tobacco control in California, Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage, Health insurance surcharges for tobacco use declined among small employers in 2018: an analysis of trends in small employer tobacco surcharges and cessation programs, Nearly half of small employers using tobacco surcharges do not provide tobacco cessation wellness programs, Evidence suggests that the ACAs tobacco surcharges reduced insurance takeup and did not increase smoking cessation. Reasons for not enrolling in marketplace coverage. In addition to the RRRs 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). Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. 13 However, if banning surcharges is not feasible, policy makers might consider limiting surcharges to below the 50% federal cap. Joint Acknowledgment/Disclosure Statement: This study was funded by a grant from the American Cancer Society (RSGI1723401CPHPS). You will be charged a $25 tobacco use premium surcharge in addition to your monthly medical plan premium if you or any dependent (age 13 and older) who is enrolled on your SEBB medical coverage uses a tobacco product. Marketing materials may be provided via Thirty-eight states also have laws in place setting the tobacco age restriction to 21. This Ballotpedia article is in need of updates. Our insurance expert will call you soon. What is the amount of the tobacco surcharge? 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. Data comes from a June 2019, MeSH States, however, can set their own rules to reduce or eliminate that surcharge and so far at least 10 have done so, including most notably California, where the permissible surcharge has been cut to to zero. 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 . This paper contributes to a small existing literature on the impact of tobacco surcharge laws on health insurance enrollment. And in states like California, Rhode Island, Vermont, the District of Columbia, Massachusetts, New York, and New Jersey are not allowed to charge higher premiums from tobacco users. Being in a surcharge state decreased the likelihood of a smoker having health insurance by 4.0 percentage points (P=.02). An employee must be able to avoid the surcharge by completing the alternative, even if the employee fails to quit smoking. A few years back it was discovered by a Health Affairs analysis that more than 16% of the small employers were using tobacco surcharge, and about half of them were not offering a tobacco cessation program. 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. 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. The state Legislature included the surcharge requirement in the state budget signed into law on June 30, 2013. We then asked respondents to select all reasons they did not enroll in a marketplace plan. 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.. 14 Within households, we defined health insurance units (HIUs) which include an individual, their spouse if they are married, and all dependent children of either the reference individual or their spouse. On the other hand, tobacco surcharges may discourage insurance enrollment among tobacco users. Accessibility Plans in both market segments are allowed to charge enrollees different rates based on the same four factors. sharing sensitive information, make sure youre on a federal 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. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. The state lowered the age of majority, which also served as a tobacco age restriction at the time, from 21 to 19 in 1976. marketing partners; and (ii) [InsureMeNow] and marketing partners may contact you with Massachusetts has many laws that govern tobacco: Tobacco excise taxes. 4 The ePub format uses eBook readers, which have several "ease of reading" features We used two important supplements to the CPS. Click here to contact us for media inquiries, and please donate here to support our continued expansion. And in states like California, Rhode Island, Vermont, the District of Columbia, Massachusetts, New York, and New Jersey are not allowed to charge higher premiums from tobacco users. Employees at several companies are pushing back on employer wellness programs that require higher health insurance premiums for tobacco users. One key difference is that tobacco users in small group plans can avoid paying the surcharge by enrolling in a tobacco cessation program. Gehr Family Center for Health Systems Science and Innovation, Our results are robust to these alternative specifications. 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. Surveys. 15 Each column is a separate regression, and the interaction term between surcharge state and current smoker shows the key differenceindifference coefficient. Descriptive statistics from linked CPSASEC and CPSTUS data pooled across 2015 and 2019. 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. It does not apply to dependents covered under the medical plan. . [14] However, the state's tobacco age restriction was raised to 21 in December 2019 by federal law. There has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge on health insurance. 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. Among states that allowed a tobacco surcharge, the statewide average of the median rating area surcharge ranged from 0% to 29.6% in 2015 and 7.0% to 32.3% in 2019. This means that health insurers can charge individual and small group tobacco users up to 50% more than non-tobacco users. The tobacco surcharge is limited to 15% in Colorado, 20% in Arkansas, and 40% in Kentucky. 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. Health Aff (Millwood). Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J. Company employs a couple thousand in the US 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. All regressions are weighted using the appropriate weights from the Current Population Survey. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults. Call KT, Davidson G, Sommers AS, Feldman R, Farseth P, Rockwood T. Uncovering the missing Medicaid cases and assessing their bias for estimates of the uninsured, The uninsured and the affordability of health insurance coverage: examining subgroups of uninsured Americans uncovers certain patterns of coverage gaps, but affordability remains a key concern, Response error and the Medicaid undercount in the current population survey, Tobacco product use among adultsUnited States, 20122013, Selfidentified tobacco use and harm perceptions among US youth, Individual Market Rate Restrictions (Not Applicable to HIPAA Eligible Individuals), Survey of NonGroup Health Insurance Enrollees, Health Insurance Exchanges 2020 Open Enrollment Report, Demand for health insurance marketplace plans was highly elastic in 20142015, Premium subsidies, the mandate, and Medicaid expansion: coverage effects of the Affordable Care Act, Demand for health insurance: evidence from the California and Washington ACA exchanges. Gary Herbert (R) in March 2019, Utah's tobacco age restriction was set to increase from 19 to 20 on July 1, 2020, and to 21 on July 1, 2021. The American Lung Association calls for the following actions to be taken by Idaho's elected officials to reduce tobacco use and exposure to secondhand smoke: Treat electronic nicotine delivery devices consistent with traditional tobacco products in all areas under state law; to not pay the monthly surcharge) for 2023. 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. Smokers living in states with high tobacco surcharges are less likely to have health insurance. This option wouldn't change the amount of the federal premium tax credit, a move foreclosed by federal law. 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. Like the Macys case, this case is still pending. The CPS is a nationally representative, longitudinal survey that follows households over the same four consecutive months for two consecutive years (ie, four months on, eight months off, four months on). 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. FOIA 54:40A-4.1 This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. 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. As of July 1, 2013, the excise tax imposed on cigarettes under M.G.L. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. For more information about legal considerations with tobacco surcharges, please connect with me atCenter for Health and Wellness Law, LLC. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. You may notice problems with 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. Since 2014 the Affordable Care Act has permitted employers and insurance companies to charge tobacco users up to 50% more in premiums. 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. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. Tobacco Users Pay Health Insurance Surcharges as per State and Federal Rules, Complete Overview on Buying Private Health Insurance Plan, Significant Differences between Public and Private Health Insurance Plan, Master the Tips to Shop for Health Insurance, Get personalized help related to Insurance Products, Service & Claims, Tips to Choose between Obamacare and Employer-sponsored Health Plans, Enrollment in Individual Health Plan is still possible after Ending of COVID SEP in the Most States, Free Health Insurance for Uninsured Americans with Stimulus Package. Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Although state tobacco rating rules typically do not apply to large employers, it is possible that there are spillover effects. An official website of the United States government. The plaintiffs state that the law requires the full reward be available upon completion of the reasonable alternative standard, which means the plaintiffs would be entitled to a refund of the $50/month penalty that they had already paid during that plan year. 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. 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. Colorado limits the tobacco surcharge to 15%. It is worth noting that the relative risk ratio for the interaction term was marginally significant for employer sponsored health insurance. Health Serv Res. USA. 8 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. Before 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. Department of Economics, There is an accommodation made for those it is unreasonably difficult to quit due to medical reasons. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. The https:// ensures that you are connecting to the Second, due to Medicaid expansions, eligibility for marketplace subsidies and Medicaid overlaps between 100% and 138% FPL in some states, but not others. The 2019 ASEC included variables that specifically identify marketplace coverage, so we examined whether the effect is driven by those with marketplace plans using the 2019 data only. Notably, smoking rates were higher among those without health insurance than those with nongroup coverage. More Benefits Insight Cafeteria Plan COLA May Require . Tobacco products are mostly used by lower-income Americans than higher-income Americans. This report must include the name of each insurance carrier on behalf of which the TPA paid. Alaska increased its tobacco age restriction from 16 to 19 in 1988. Tobacco. Agents are available: Mon - Fri, 8 AM - 8 PM ET. Careers. It was then decreased from 21 to 19 in 1963. The tobacco age restriction across the country is 21 as a matter of federal law. 1 Tobacco users can . Pesko MF, Maclean JC, Kaplan CM, Hill SC. The surcharge is an extra charge on your health plan if you're a tobacco user or for those who don't partake, they may receive a discount. [2] After June 2015, eighteen other states raised their tobacco age restriction to 21. By 1920, 46 states had implemented an age limit for tobacco sales, of which 14 set the limit at 21. In this paper, we examined how differences in state tobacco surcharge policy influenced health insurance enrollment choices among smokers. The tobacco cessation wellness program is designed to promote health and prevent disease. Albeit if a person with an average premium is subjected to a 50% tobacco surcharge, then their monthly premium would increase to $864 per month, and their premium subsidy would not change. USA, 2 Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. **Please Note: Nothing contained in this blog post is to be construed as legal advice. [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. Kaplan CM, Kaplan EK. 5 and text messages is not a condition for purchase. Specifically, our model compares the insurance status of smokers to nonsmokers across states with and without tobacco surcharges. Comparison of demographic characteristics by primary insurance type for nonelderly adults. 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. PROOF OF AGE MAY BE REQUIRED FOR PURCHASE. Objective: State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. Employers that are ALEs (i.e., have 50 or more full-time equivalent employees . Credit Card Surcharge Laws by State: A Guide for AEC Pros. Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage. In order to examine health insurance enrollment by tobacco use, we linked data from both CPSASEC and CPSTUS. Consistent with the family income calculation for health insurance qualification, we excluded income under $12200 for dependents. 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