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). Abbreviations: AGI, Adjusted Gross Income; FPL, Federal Poverty Level; HIU, Health Insurance Unit; SD, standard deviation. This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states. Learn 4 tips for making your tobacco cessation program more successful. Even though federal law permits a tobacco surcharge on health insurance, some states prohibit this. Kentucky Information Unauthorized use of these marks is strictly prohibited. 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. 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 individual can make a request to involve a personal physicians recommendation at any time and the personal physician can adjust the physicians recommendations at any time, consistent with medical appropriateness. Web(OEBB). This blog post is for informational and educational purposes only. 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. 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). WebUPS prohibits the shipment of Cigarettes or Little Cigars (as defined below) to consumers, regardless of destination state. Other states like Kentucky, Arkansas, and Colorado allow a lower premium differential than federal law. , This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. 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. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. 
Accessibility It is also necessary to consider how the tobacco surcharge may impact affordability for applicable large employers (50 or more FTEs) subject to 4980H USA, 2 Figure1 shows the results from our survey of uninsured tobacco users with incomes above 138% FPL. government site. Principal findings: 
affordable care act, enrollment, health insurance, marketplace, premiums, smoking, tobacco surcharge, State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment. This paper contributes to a small existing literature on the impact of tobacco surcharge laws on health insurance enrollment. However, our models adjusted for other state policies that may affect insurance enrollment and tobacco use. County populations were pulled from the 2014 and 2018 American Community Survey annual county level estimates and aggregated up to the rating area level. This website uses cookies to improve content delivery. Maximum non-tobacco and tobacco-related incentives (50%) difference permitted 8 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. The sample is limited only to states that allowed a tobacco surcharge and participated in the federal exchange. 41% of respondents said this was the main reason they did not enroll, and 54% said it played a factor in their decision. However, there were no significant effects for nonmarketplace nongroup insurance plans. 14 It is worth noting that the relative risk ratio for the interaction term was marginally significant for employer sponsored health insurance. Health Aff (Millwood). 28 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. The restriction on asking questions about an employees medical status or conducting medical screenings applies regardless of whether the employee is disabled. 
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. , Additionally, recent research has cast doubt on whether small employers complied with either the rating rules or the exemption for tobacco cessation, particularly in the early years of the ACA. 22 Study design: 12 All columns are derived from a single multinomial logit regression, and each column presents the relative risk ratios (RRR), comparing the risk of being in the insurance type of interest and being uninsured. 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. 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. Another potential consideration is the effect of tobacco surcharges on nonusers. All tobacco users may have their tobacco surcharge removed by completing the wellness requirements outlined in the applicable The total premium difference must not exceed 50% of the total cost of employee-only coverage under the plan (or, if an employees family can participate in the cessation program, the premium difference must not exceed 50% of the total cost of coverage in which an employee and any dependents are enrolled). sharing sensitive information, make sure youre on a federal The https:// ensures that you are connecting to the 
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. We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. 
Data comes from a June 2019 online survey of tobacco users using Qualtrics Research Panel collected and analyzed by the authors. 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. 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.. We found that among individuals without insurance through an employer or public program, living in a surcharge state decreased the probability that a smoker enrolled in a nongroup plan by 0.9.0 percentage points (P<.01). $360. 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. 64C increased from 30% to 40% of the wholesale price of the products, and smokeless tobacco products increased from , We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. Want updates on the latest lung health news, including COVID-19, research, inspiring stories and health information? 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. 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. stop using tobacco or Colorado limits the tobacco surcharge to 15%. The results indicate that smokers were at an decreased risk of being in a nongroup plan or an employer plan relative to being uninsured. These legal requirements include ACA, Americans with Disabilities Act (ADA), and other civil rights laws considerations. Our models test the effect of the surcharge on enrollment and do not provide evidence of higher enrollment among nonusers. 3 That is, it must have a reasonable chance of improving the health of, or preventing disease in, participating individuals, and it should not be overly burdensome. In addition to the double coverage surcharge, PEBB is adding the Tobacco Use and Spouse/Domestic Partner Other Group Coverage surcharge rules to PEBB Oregon Administrative Rules. WebA $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 Notably, using data from the Behavioral Risk Factor Surveillance System, Freidman and colleagues found the probability of having insurance was reduced among smokers in states with high tobacco surcharges relative to states without surcharges. There has been a flurry of activity lately involving employer wellness programs that impose a tobacco surcharge on health insurance. 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. To achieve this, health-contingent tobacco cessation programs must allow a reasonable alternative standard (or a waiver for not meeting the initial requirement of not being a tobacco user) for obtaining the lower premium for any individual for whom, for that period, it is unreasonably difficult due to a medical condition or medically inadvisable to satisfy the initial standard. High premiums and tobacco surcharges are reported by smokers to be barriers to enrollment in marketplace coverage. Relative risk ratios from multinomial logit regression on type of health insurance plan. 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. We used two important supplements to the CPS. Eliminating tobacco surcharges or substantially limiting them is an option that state policy makers may consider in order to increase health insurance coverage among this particularly vulnerable population. 2. affordable care act; enrollment; health insurance; marketplace; premiums; smoking; tobacco surcharge. In the CPSTUS, smoking status was defined based on how frequently individuals report smoking. 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. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults. Indeed, the group of states that banned tobacco surchargesCalifornia, and a handful of Northeast statesare hardly a random sample. 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. 2020 Sep;39(9):1540-1545. doi: 10.1377/hlthaff.2020.00015. It is important to note that surcharging is not legal in all states or countries, and there may be restrictions on when and how it can be applied. 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. September 29, 2021. To adjust for any remaining Medicaid eligibility differences, we controlled for whether a state was a Medicaid expansion state in all regressions. Tobacco use is the largest cause of preventable disease and death in the United States, Allowing higher premiums for tobacco use in the nongroup market results in lower health insurance enrollment among smokers, which is driven by decreased enrollment in the nongroup market. All plans offered on the marketplace adhere to the ACA tobacco surcharge restrictions; however, more than half of nongroup plans offered outside of the marketplaces are not ACA compliant. Federal government websites often end in .gov or .mil. Kaplan CM, Kaplan EK. Trends over time in enrollment in nongroup health insurance plans by tobacco use in the United States. 9 First, there is known overreporting of nongroup health insurance plan participation among Medicaid eligible respondents in survey data including the CPS. In those programs, incentives are tied to achieving a health status goal, such as not using tobacco or having a certain weight or blood pressure (outcomes-based). Bookshelf 6.Should employers be concerned about state smoker Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. Federal government websites often end in .gov or .mil. Three states -- Arkansas, Colorado, and Kentucky -- will allow companies to charge tobacco users less than 50%. The ACA requires that all health insurance plans provide tobacco cessation and lung cancer screening with no outofpocket costs. One of the most important aspects of the Affordable Care Act (ACA) was the introduction of modified community rating in the nongroup insurance market, which drastically changed how premiums could be set. 64C increased to $3.51 per pack. CHANGES TO RULE: 101-020-0052 Surcharges (1) For the purposes of this rule, the following definitions apply: 10 The https:// ensures that you are connecting to the 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. This site needs JavaScript to work properly. , In other words, according to the plaintiffs, the employer did not give them a reasonable alternative standard, like a tobacco cessation program, to avoid the $50/month surcharge. The extra money being saved by participation is impossible to pass up given their financial situation. 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. 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. Web2 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. Read our simple and effective tips for protecting you and your family from the dangers of air pollution. 13 Additionally, our identification strategy relies on the assumption that states that do not have tobacco surcharges do not have other unobservable characteristics that may differentially impact enrollment for tobacco users and nonusers that are not accounted for in our model. WebAlthough the federal law allows states to limit the surcharge to less than 50 percent, or to adopt a narrower definition of tobacco use, most states, including Kansas, have Although federal regulations require that plans charge tobacco users no more than 50% higher premiums, several states have more strict regulations. The table presents relative risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all income levels. All regressions are weighted using the appropriate weights from the Current Population Survey. $135. According to our estimates, the presence of a tobacco surcharge decreased the likelihood of enrollment in a nongroup plan by 9.0 percentage points (P<.01) among smokers without insurance through an employer or public program. For more information about legal considerations with tobacco surcharges, please connect with me at Center for Health and Wellness Law, LLC. This material must include contact information for obtaining a reasonable alternative standard and a statement that recommendations of an individuals personal physician will be accommodated. 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. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program. 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. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. 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. 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. Also, an individual must be given the opportunity to comply with the recommendations of the individuals personal physician as a second reasonable alternative standard to meeting the reasonable alternative standard defined by the plan, but only if the physician joins in the request. Our results were not sensitive to the use of the alternative definition of tobacco use including the use of other tobacco products. Since tobacco surcharges can be set at the state level, this policy may be more easily altered than other aspects of the ACA which are subjected to federal regulation. sharing sensitive information, make sure youre on a federal 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). In order to provide context to our results on the reasons tobacco users did not enroll in health insurance, we also included separate data from a June 2019 online survey conducted using Qualtrics Research Panel. Tobacco surcharges and the state laws that limit them theoretically have varying effects on different segments of the health insurance market. 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. 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. Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. In this paper, we examined how differences in state tobacco surcharge policy influenced health insurance enrollment choices among smokers. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. 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. 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. , Keck School of Medicine, 24 FOIA One important limitation of our study is that although we compare enrollment rates by smoking status, smoking status is not experimentally varied across groups. We found that living in a surcharge state decreased the probability of enrolling in a nongroup plan by 13.3 percentage points (P<.01) among these individuals who are most likely to benefit from the marketplacesthose with incomes over 138% FPL who do not have insurance through their employer or a public program. 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