Those on employer health plans can avoid the surcharge by joining an employer based tobacco cessation program. Standard errors, clustered at the state level are shown in parentheses. Surveys. Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J. Access to insurance and health care may be particularly important for tobacco users because they are at higher risk of developing numerous chronic health conditions and because all health insurance plans are required to provide tobacco cessation as an essential health benefit with no outofpocket costs. This means that health insurers can charge individual and small group tobacco users up to 50% more than non-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. Health Aff (Millwood). Tobacco Surcharges Associated With Reduced ACA Marketplace Enrollment. A $50 monthly tobacco surcharge will be applied to employees who declare tobacco usage. Bethesda, MD 20894, Web Policies Department of Economics, Critics of surcharge policies point to data from other health-contingent premium programs showing that they fail to change individuals' behavior. **, Founder and President, Center for Health and Wellness Law, LLC. The tobacco products that are counted include traditional cigarettes, cigars, chewing tobacco, e-cigarettes, vaping, and pipe smoking. Policy: Christopher Nelson Caitlin Styrsky Molly Byrne Katharine Frey Jimmy McAllister Samuel Postell Reasons for not enrolling in marketplace coverage. 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. USA. Our main source of data was the Current Population Survey (CPS). Kaplan CM, Kaplan EK. 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. 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. The ePub format uses eBook readers, which have several "ease of reading" features External Relations: Moira Delaney Hannah Nelson Caroline Presnell 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). 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. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P=.01). Although we did not have data from other years, the fact that our results were similar across the two years gives us confidence that pooling the data is a valid approach. In addition, 14 percent used . Section 1302 (c) (1) limits out-of-pocket costs and, for small group market plans, section 1302 (c) (2) limits deductibles. 21 Plans in both market segments are allowed to charge enrollees different rates based on the same four factors. As such, several previous studies have shown that gaining access to health insurance can have large effect on both quitting smoking and cancer screening. Reasons for not enrolling in marketplace coverage. Table TableA1:A1: AppendixS1 presents summary statistics by insurance type separately for the 2015 and 2019 samples. The survey included tobacco users age 1864 with incomes above. To adjust for other potential differences across states, we controlled for Medicaid expansion status, the use of a statebased marketplace, tobacco taxes, and clean indoor air policies. 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. 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. Although state tobacco rating rules typically do not apply to large employers, it is possible that there are spillover effects. In order to examine health insurance enrollment by tobacco use, we linked data from both CPSASEC and CPSTUS. First, there is known overreporting of nongroup health insurance plan participation among Medicaid eligible respondents in survey data including the CPS. Descriptive statistics from linked CPSASEC and CPSTUS data pooled across 2015 and 2019. The "tobacco surcharge" won't be offset by federal tax credits, hitting smokers with a double whammy. See this image and copyright information in PMC. surcharge cannot exceed 50 percent of the total cost of health coverage. 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. It was then decreased from 21 to 19 in 1963. First, each March, participants respond to the Annual Social and Economic Supplement (CPSASEC), which includes detailed questions about the source and type of health insurance coverage as well as exhaustive income and employment questions. 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. Figure1 shows the results from our survey of uninsured tobacco users with incomes above 138% FPL. However, since theoretically tobacco surcharges should primarily affect the decision to purchase nongroup insurance, our preferred specification excluded individuals who had insurance either through an employer or a public program such as Medicare, Medicaid, or Military insurance. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. 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 used two important supplements to the CPS. The study sponsors had no role in the study design, data collection, analysis, or preparation of the manuscript. Finally, we supplemented our main findings with qualitative data from a survey that provides more contexts for how tobacco surcharges may influence enrollment in nongroup plans. 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. 18. Finally, we gathered data on tobacco surcharges from the CMS Health Insurance Exchange Public Use Files for 2015 and 2019. By limiting the sample respondents in states with tobacco surcharges, we were able to estimate the effect of the size of the surcharge on insurance enrollment. 2 Reasons for not enrolling in marketplace coverage. Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. 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. State fixed effects were included in columns (2) and (4) include state fixed effects; however, they did not substantially affect the results. More specifically, our results show that tobacco surcharges have a large negative impact on enrollment in nongroup plans sold on the ACA marketplaces among those without insurance through an employer or public program. 2 However, organizations like the American Cancer Society and the American Lung Association believe that higher health insurance premiums for tobacco users make health coverage less accessible to people using tobacco. Health Aff (Millwood). September 29, 2021. For the purposes of this study, we limited the sample to uninsured individuals (N=519). Compliance Overview: Tobacco Surcharges Legal Rules April 30, 2019 By Lesa M. Votovich As employers continue to show more interest in adding wellness programs to their employee benefit plans, they must also be cognizant of any federal and/or state laws that could impact the components of these programs. , However, if banning surcharges is not feasible, policy makers might consider limiting surcharges to below the 50% federal cap. 3 We linked data from two components of the Current Population Surveythe 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. Eight states increased their restrictions under a Democratic trifecta, four increased their restrictions under a Republican trifecta, and seven increased their restrictions under divided government. Liber AC, Drope JM, Graetz I, Waters TM, Kaplan CM. This report must include the name of each insurance carrier on behalf of which the TPA paid. 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. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. If you would like to help our coverage grow, consider donating to Ballotpedia. You do not have to pay this surcharge if you attest (respond) that: You and all enrolled dependents ages 13 and older do not use tobacco products. 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. Premium rating rules for nongroup insurance and small group plans (generally plans provided by employers with fewer than 50 employees) are similar. 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. Income eligibility for assistance under the affordable care act: technical memorandum on estimates for nonelderly adults. Columns 3, 4, and 5 show results limiting the sample to individuals with incomes above 138% FPL, which includes those who have incomes too high to qualify for Medicaid under the expansions, but who are eligible for subsidies in the marketplaces and are thus more likely to be affected by tobacco surcharges. there is yet little evidence that insurance surcharges lead to changes in tobacco use. This is due to a "tobacco surcharge". Nearly Half Of Small Employers Using Tobacco Surcharges Do Not Provide Tobacco Cessation Wellness Programs. The surcharges are extra costs that have been added to PEBB benefit eligible WSU employees' standard monthly medical premiums, effective July 1, 2014. Consent for marketing calls The ERISA wellness incentive laws have been in effect in their current form since 2013, which is a long time to get into compliance. 2. Tobacco users will pay a surcharge for their health plan coverage beginning July 1, 2022. In some of the circumstances, there may not be any surcharge for tobacco users. 64C increased to $3.51 per pack. The Affordable Care Act brought dramatic changes to the individual and small group health insurance premiums still, the use of tobacco by a person can affect the price one pays for the health coverage. 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. 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. We measured individual and household characteristics to be used as covariates in our regression models from CPSASEC. 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. 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. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. 4 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. [4] On December 20, 2019, President Donald Trump (R) signed H.R. 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. 9 University of Southern California, the display of certain parts of an article in other eReaders. We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. 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. Los Angeles We then asked respondents to select all reasons they did not enroll in a marketplace plan. 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 If the program imposes a tobacco surcharge based on whether participants smoke (or otherwise use tobacco), participants who request an alternative standard must be offered a reasonable one,. Albeit, the use of tobacco for religious or ceremonial purposes are excluded from the rule. 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. Since 2014, all nongroup health insurance plans, including those sold on the individual marketplaces, can only rate premiums based on four characteristics: age, family size, geographic region, and tobacco use. Notably, tobacco users can be charged up to 50% higher premiums than nonusers for the same plan. 14 Loyola Marymount University, See details about the 5-factor test in my previous blog post, What Is a Tobacco Surcharge and How Does My Company Offer One? Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. 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. The employer can apply the tobacco surcharge only if the employees do not participate in the tobacco cessation program. Gehr Family Center for Health Systems Science and Innovation, In November 2021, the Ohio District Court ruled that the DOLs case can move forward with the alleged tobacco surcharge violations for plan years 2011-2013. For example, tobacco surcharges could lead to less employer coverage as a result of higher premiums for tobacco users in the small group market or if large employers were more likely to charge surcharges in states that allowed them in small group and nongroup markets. Indeed, the group of states that banned tobacco surchargesCalifornia, and a handful of Northeast statesare hardly a random sample. 2. Clipboard, Search History, and several other advanced features are temporarily unavailable. Tobacco use is the largest cause of preventable disease and death in the United States, [9][10] The tobacco age restriction remained at 19 until federal law raised it to 21 in December 2019. The employer determined tobacco use status through an affidavit completed by each employee covered under the employer group health plan. Column 1 shows the effect of tobacco surcharges on the differences in insurance rates between smokers and nonsmokers for the full sample of nonelderly adults. Instead, the employer gave employees only two options: 1) dont use tobacco and avoid the surcharge; or. 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. Youth access to tobacco law-RCW 70.155: Prohibits the sale and distribution of tobacco products to minors. What is the amount of the tobacco surcharge? Please email us if you would like to suggest a revision. Although evidence suggests that tobacco taxes and other policies that increase the cost of smoking have a direct impact on smoking, 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. 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. 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Even though we wont know the final outcomes of either case described above for a while, we can still draw lessons from these cases. It is now looking at a state-by-state approach to work on rolling back . An employer cannot set a deadline by which an employee can no longer use tobacco. 64C increased from 30% to 40% of the wholesale price of the products, and smokeless tobacco products increased from 90% to 210% of the wholesale price. 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. Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. The interaction terms between surcharge state and current smoker show the key differenceindifference results. To learn more: Call 1-866-NY-QUITS (1-866-697-8487) toll free; Text (716) 309-4688; or. 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. 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. 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. 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 . Several states have set more restrictive limits on rating for tobacco users with incomes above 138 % FPL surchargesCalifornia... 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