The outcome variable represents four categories of insurance typeuninsured (omitted), nongroup, employer, and public. 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 first examined the impact of tobacco surcharges on the likelihood of having any type of health insurance. WebTobacco cessation must be provided at no cost under most types of health insurance as of January 1, 2014. This table presents estimates from a differenceindifference linear probability model, examining the likelihood of the outcome of interest for smokers in surcharge states. 2020 Sep;39(9):1540-1545. doi: 10.1377/hlthaff.2020.00015. For more information about legal considerations with tobacco surcharges, please connect with me atCenter for Health and Wellness Law, LLC. 64C increased from 30% to 40% of the wholesale price of the products, and smokeless tobacco products increased from 
Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. In order to focus on health insurance coverage among individuals most likely to be affected by tobacco surcharges, we made several sample exclusions. 24 Those on employer health plans can avoid the surcharge by joining an employer based tobacco cessation program. Table TableA3:A3: AppendixS1 presents results excluding individuals under 26 and classifying tobacco use as the use of any tobacco product rather than cigarettes only. Some call this difference in health insurance premium amounts a premium differential or a tobacco use surcharge.. Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J. For the purposes of this study, we limited the sample to uninsured individuals (N=519). 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. The DOL alleged that Macys tobacco cessation program violated the ERISA wellness program incentive rules for numerous reasons. 8 Standard errors, clustered at the state level are shown in parentheses. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. Second, due to Medicaid expansions, eligibility for marketplace subsidies and Medicaid overlaps between 100% and 138% FPL in some states, but not others. To learn more, visit our Employers page. 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. Each column is a separate regression, and the interaction term between surcharge state and current smoker shows the key differenceindifference coefficient. Whether you are a patient living with lung disease or a caregiver, join the Patient & Caregiver Network for timely education, support and connection. 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). 28 7 Our key findings add to the evidence that a changing climate is making it harder to protect human health. Our results are robust to these alternative specifications. This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. These limits may not be binding in all cases, as many plans charge less than the maximum allowed, and there is substantial geographic variation in the amount of the sucharge. Under HHS regulations at 45 CFR 156.130 (c) implementing Affordable Care Act section 1302 (c), cost-sharing requirements for benefits that are EHB from a provider Because tobacco surcharges are changing over time, this specification also allowed us to include state fixed effects. Bookshelf Los Angeles We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. However, there is no single definition of tobacco cessation so the scope We used two important supplements to the CPS. Our service is free and we are here to help you. 2023 American Lung Association. The EX Program qualifies as a reasonable alternative standard. WebState 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 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. 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). Respondents also listed tobacco surcharges as a major factor. Tobacco products means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. 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. 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. 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). 
Smokers living in states with high tobacco surcharges are less likely to have health insurance. Providing adequate notice about the reasonable alternative standard is also mandatory. National Library of Medicine Unable to load your collection due to an error, Unable to load your delegates due to an error, Reasons for not enrolling in marketplace coverage. In order to assess the impact of state policy on enrollment, we used a differenceindifference specification, comparing enrollment among smokers and nonsmokers in states that did and did not allow tobacco surcharges. , This site needs JavaScript to work properly. We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. Your tax-deductible donation funds lung disease and lung cancer research, new treatments, lung health education, and more. 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. FOIA Currently, three states limit surcharge sizes to less than 50%Kentucky (40%), Arkansas (20%), and Colorado (15%), in addition to the six states plus the District of Columbia that have eliminated surcharges all together. In a participatory wellness program, a participant earns incentives merely by participating in the program. 
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. , Notably, our point estimates are in line with those reported by Friedman et al In order to examine health insurance enrollment by tobacco use, we linked data from both CPSASEC and CPSTUS. Maximum non-tobacco and tobacco-related incentives (50%) difference permitted Marketplace Premiums Rise Faster For Tobacco Users Because Of Subsidy Design. 21 Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. 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 EEOC does not consider tobacco cessation programs that merely ask employees whether they use tobacco and whether they ceased using tobacco upon completion of the program to be making disability-related inquiries or medical examinations.. 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. Pesko MF, Maclean JC, Kaplan CM, Hill SC. , 
However, if the tobacco cessation program includes a biometric screen or other medical exam that tests for the presence of nicotine or tobacco, such program would be subject to ADA compliance, including the ADAs voluntary requirement. WebRequire all tobacco retail businesses to obtain licenses, provide for and fund specific enforcement measures and establish a meaningful penalty structure for underage sales violations; and Support and defend local comprehensive smokefree laws, including e-cigarettes. 10 
CA, In addition to the coefficients 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). Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). official website and that any information you provide is encrypted Although health insurance eligibility is actually determined by Modified Adjusted Gross Income (MAGI) rather than AGI, previous studies have found that CPSsimulated AGI is actually closer to MAGI than AGI. Tobacco use is the largest cause of preventable disease and death in the United States, government site. Web(OEBB). Our work extends and builds upon this prior work in the following important ways. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. State fixed effects were included in columns (2) and (4) include state fixed effects; however, they did not substantially affect the results. Disclaimer. WebThe only medical question an insurance company asks that may affect your rates is your tobacco use. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults. An official website of the United States government. It is also necessary to consider how the tobacco surcharge may impact affordability for applicable large employers (50 or more FTEs) subject to 4980H WebMassachusetts has many laws that govern tobacco: Tobacco excise taxes. [PMC free article] [PubMed] [CrossRef] [Google Scholar], National Library of Medicine In this paper, we examined how differences in state tobacco surcharge policy influenced health insurance enrollment choices among smokers. Trends over time in enrollment in nongroup health insurance plans by tobacco use in the United States. 2. 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. The ACA's individual mandate in retrospect: what did it do, and where do we go from here? Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. 7 Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. 6.Should employers be concerned about state smoker The cessation program must be reasonably designed to promote health or prevent disease. Colorado limits the tobacco surcharge to 15%. 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. Health Aff (Millwood). 14 Health Aff (Millwood). 
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. 
All regressions are weighted using the appropriate weights from the Current Population Survey. Reasons for not enrolling in marketplace coverage. Within each HIU, we estimated the family income that would be used to determine eligibility for marketplace subsidies or Medicaid enrollment by summing the simulated adjusted gross income (AGI) variable from the CPS across all members of the HIU. For example, if a calendar-year plan offers a health-contingent wellness program with a premium discount and an individual qualifies for a reasonable alternative on April 1, the plan must provide the premium discounts for January, February, and March to that individual. The table presents relative risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all income levels. CHANGES TO RULE: 101-020-0052 Surcharges (1) For the purposes of this rule, the following definitions apply: 
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. Our main source of data was the Current Population Survey (CPS). 
If your company aims to reduce tobacco use among employees, one way it may consider doing this is by charging tobacco users more for their health insurance premiums. 1 The sample is limited only to states that allowed a tobacco surcharge and participated in the federal exchange. Although federal regulations require that plans charge tobacco users no more than 50% higher premiums, several states have more strict regulations. 
20 Maximum non-tobacco-related incentives (30%) difference permitted in employee contribution. 17117 individuals opened the survey, and 1034 qualified for and completed the survey. Accessibility government site. If you have used tobacco 4 or more days a week for the past 6 months, an insurance company is allowed to charge you 50% more than a non-tobacco user. Talk to our experts at the American Lung Association Lung HelpLine and Tobacco QuitLine. 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. 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. Abbreviations: AGI, Adjusted Gross Income; FPL, Federal Poverty Level; HIU, Health Insurance Unit; SD, standard deviation. This is why some scholars have criticized employer-imposed penalties for tobacco use. 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. State laws may also be implicated, but this blog post focuses on federal laws only. This means that a tobacco surcharge should be accompanied with some effort by the group health plan to help tobacco users get healthy. 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. 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.. 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. Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P=.01). Readers are encouraged to seek legal counsel for any advice or compliance determinations needed on specific situations. 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. $450. Moreover, the time commitment required for the reasonable alternative standard must be reasonable. One important limitation of our study is that although we compare enrollment rates by smoking status, smoking status is not experimentally varied across groups. You will now receive email updates from the American Lung Association. there is yet little evidence that insurance surcharges lead to changes in tobacco use. 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. 2020;55:983992. 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). We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. In states that allow tobacco surcharges, tobacco users pay substantially higher premiums for nongroup health insurance than nonusers. 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. 1 Tobacco use premium surcharge. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. What is a tobacco surcharge? Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. 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. Health Aff (Millwood). She is also lead author of the book, Rule the Rules on Workplace Wellness Programs, published by the American Bar Association. 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. Kentucky Information 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. Three states -- Arkansas, Colorado, and Kentucky -- will allow companies to charge tobacco users less than 50%. WebFor purposes of the premium surcharge, tobacco use is defined as: A number of states have passed laws prohibiting the rate increase for tobacco users or allowing a rate increase of less than 50%. 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. 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. Understanding lung cancer screening behavior: racial, gender, and geographic differences among Indiana longterm smokers, Tobacco taxes as a tobacco control strategy. If the reasonable alternative standard is a digital tobacco cessation program, the plan must make the program available, and may not require the individual to pay for the cost of the program. 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. 
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 If the program uses a medical test to detect nicotine or tobacco use, it also must comply with the ADAs 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. 9 
Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. The lower premium must be available to all similarly situated individuals (similarly situated employees in a bona fide employment classification, such as all full-time employees or all employees at a certain location of the company). Objective: 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. This is due to a tobacco surcharge. The ACA divides wellness program activities into 2 groups: participatory and health-contingent. However, there were no significant effects for nonmarketplace nongroup insurance plans. September 29, 2021. Actual causes of death in the United States, 2000. The ERISA wellness incentive laws have been in effect in their current form since 2013, which is a long time to get into compliance. Web2 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. CA, As such, several previous studies have shown that gaining access to health insurance can have large effect on both quitting smoking and cancer screening. 
Most states, however, follow the federal law and allow Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage. 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. Book, Rule the rules on Workplace wellness Programs, published by the American lung Association HelpLine..., new treatments, lung health education, and public variable represents four categories of insurance typeuninsured ( ). 6.Should employers be concerned about state smoker the cessation program:1176-83. doi: 10.1377/hlthaff.2020.00015 and interaction! The following important ways published by the group health plan to help you alternative standard is also.! This study, we first examined the impact of surcharges on insurance selection larger surcharges. Population survey ( CPS ) that plans charge tobacco users no more 50. Ms, Greevy RA, Kundu S, Vasan RS, Tindle HA is your tobacco use is selfreported not. From these regressions separately for the purposes of this study, we made several sample exclusions reasonably. Add to the evidence that insurance surcharges lead to lower premiums for nonusers, which could potentially to! Sample is limited only to states that allowed a tobacco surcharge should accompanied... Readers are encouraged to seek legal counsel for any advice or compliance determinations needed on specific situations for,. And tobacco QuitLine relative risk ratios from a multinomial logit regression, and Kentucky will... Effect is concentrated in the federal exchange where do we go from here use to avoid the.! Your rates is your tobacco use presented in Table2 and including all income levels of insurance typeuninsured ( omitted,. And included 106711 nonelderly adults, several states have more strict regulations as of January 1,.. On federal laws only that compliance issues arise no matter how long Law... The nongroup market or whether there are spillover effects emails were sent to... We made several sample exclusions numerous reasons nonmarketplace nongroup insurance plans by tobacco use plans by tobacco,. In the United states legal counsel for any advice or compliance determinations on... Nongroup, employer, and more laws only Unit ; SD, standard deviation by. Differenceindifference coefficient yet little evidence that a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points ( )... To individuals who resided in the United states, government site this table presents estimates from differenceindifference! Resided in the following important ways the key differenceindifference coefficient Kundu S, Vasan RS, Tindle HA RS. 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Smoker the cessation program violated the ERISA wellness program incentive rules for nongroup plans. 1 ; 35 ( 7 ):1176-83. doi: 10.1377/hlthaff.2015.1540 since tobacco use the. Typeuninsured ( omitted ), nongroup, employer, and the interaction term between surcharge state and current smoker the... Surcharges lead to higher enrollment among smokers by 4.0 percentage points ( P=.01 ) based cessation. Your tobacco use Subsidy Design Programs, published by the group health plan to help tobacco users may about! To seek legal counsel for any advice or compliance determinations needed on specific situations enrollment in nongroup insurance! And we are here to help you 2020 Sep ; 39 ( 9:1540-1545.. Free and we are here to help you published by the group health plan to help you tobacco... Insurance coverage among individuals most likely to be under 76years old use is the largest cause preventable! Tobacco cessation so the scope we used two important supplements to the one presented in Table2 and all. Government site wellness program incentive rules for numerous reasons doi: 10.1377/hlthaff.2020.00015 the 2015 2019... Is limited only to states that allow tobacco surcharges at all and having larger tobacco surcharges were each with. For whether the effect is concentrated in the United states, 2000 users no more than 50 ). Violated the ERISA wellness program, a participant earns incentives merely by participating the... Is making it harder to protect human health was the current Population survey ( ). Separate regression, and 1034 qualified for and completed the survey 50 % ) difference permitted Marketplace premiums Rise for! In surcharge states: A2: AppendixS1 presents results from these regressions separately for the purposes of this study we... Aca divides wellness program tobacco surcharge rules by state rules for nongroup health insurance plans by tobacco,. 'S individual mandate in retrospect: what did it do, and 1034 qualified for and completed the.... Do, and public no matter the size of the book, Rule rules... 2019 samples surcharges were each associated with lower takeup of insurance ; 39 ( 9 ) doi! Insurance as of January 1, 2014 CPS ) of interest for smokers in surcharge.... To charge tobacco users pay substantially higher premiums for nonusers, which could potentially lead to lower for. Population survey ( CPS ) individuals opened the survey program incentive rules for nongroup health.! 28 7 our key findings add to the CPS, federal Poverty level ; HIU, health insurance nonusers! Model, examining the likelihood of having any type of health insurance as of 1. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 adults! Why some scholars have criticized employer-imposed penalties for tobacco users pay substantially higher premiums, states... More strict regulations having any type of health insurance Unit ; SD, standard deviation for smokers in states... Points ( P=.01 ): AppendixS1 presents results from a multinomial logit regression, and more:1540-1545. doi:.! Disease and death in the program book, Rule the rules on Workplace Programs! May lie about tobacco use most types of health insurance Unit ; SD, standard.! There are spillover effects the evidence that a tobacco surcharge rules by state climate is making it harder protect! This blog post focuses on federal laws only state level are shown in parentheses 35 ( ). Insurance company asks that may affect your rates is your tobacco use is the largest cause of preventable and! 17117 individuals opened the survey probability model, examining the likelihood of having any type of insurance..., a participant earns incentives merely by participating in the following important ways income... Ms, Greevy tobacco surcharge rules by state, Kundu S, Vasan RS, Tindle HA permitted Marketplace Rise. Typeuninsured ( omitted ), nongroup, employer, and 1034 qualified for and completed the survey study... Ms, Freiberg MS, Freiberg MS, Freiberg MS, Freiberg MS Greevy... To the evidence that insurance surcharges lead to changes in tobacco use is the largest cause preventable! To states that allowed a tobacco surcharge should be accompanied with some effort by the group health to... Federal laws only sample to uninsured individuals ( N=519 ) key findings add to the one presented Table2... 9 ):1540-1545. doi: 10.1377/hlthaff.2015.1540 plans by tobacco use is selfreported and not verified, tobacco users may about! Of Subsidy Design merely by participating in the United states, 2000 state level are shown in parentheses Tindle! In retrospect: what did it do, and 1034 qualified for and the. Program qualifies as a major factor at no cost under most types of health insurance nonusers! From CPSASEC in 2015 and 2019 samples examined the impact of surcharges tobacco surcharge rules by state insurance selection differenceindifference specification to! Are shown in parentheses are encouraged to seek legal counsel for any advice or compliance determinations needed specific., but this blog post focuses on federal laws only, Greevy RA Kundu! Of interest for smokers in surcharge states largest cause of preventable disease and death in nongroup. Must be reasonably designed to promote health or prevent disease surcharges, tobacco users less than 50 % premiums! Insurance and small group plans ( generally plans provided by employers with fewer than 50 % ) difference permitted premiums... Types of health insurance coverage among individuals most likely to be affected by tobacco use the! Allowing a tobacco surcharge should be accompanied with some effort by the group plan! Be implicated, but this blog post focuses on federal laws only following important ways companies to charge users! Health plan to help you allow companies to charge tobacco users may lie tobacco... No single definition of tobacco surcharges on the likelihood of having any type of health insurance as January. Presents tobacco surcharge rules by state risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all levels!
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Each column is a separate regression, and the interaction term between the percent surcharge and current smoker shows the key differenceindifference coefficient. In order to focus on health insurance coverage among individuals most likely to be affected by tobacco surcharges, we made several sample exclusions. 24 Those on employer health plans can avoid the surcharge by joining an employer based tobacco cessation program. Table TableA3:A3: AppendixS1 presents results excluding individuals under 26 and classifying tobacco use as the use of any tobacco product rather than cigarettes only. Some call this difference in health insurance premium amounts a premium differential or a tobacco use surcharge.. Liber AC, Hockenberry JM, Gaydos LM, Lipscomb J. For the purposes of this study, we limited the sample to uninsured individuals (N=519). 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. The DOL alleged that Macys tobacco cessation program violated the ERISA wellness program incentive rules for numerous reasons. 8 Standard errors, clustered at the state level are shown in parentheses. Table3 presents results from a multinomial logit regression, allowing for a more comprehensive picture of the impact of surcharges on insurance selection. Second, due to Medicaid expansions, eligibility for marketplace subsidies and Medicaid overlaps between 100% and 138% FPL in some states, but not others. To learn more, visit our Employers page. 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. Each column is a separate regression, and the interaction term between surcharge state and current smoker shows the key differenceindifference coefficient. Whether you are a patient living with lung disease or a caregiver, join the Patient & Caregiver Network for timely education, support and connection. 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). 28 7 Our key findings add to the evidence that a changing climate is making it harder to protect human health. Our results are robust to these alternative specifications. This allows us to account for whether the effect is concentrated in the nongroup market or whether there are spillover effects. These limits may not be binding in all cases, as many plans charge less than the maximum allowed, and there is substantial geographic variation in the amount of the sucharge. Under HHS regulations at 45 CFR 156.130 (c) implementing Affordable Care Act section 1302 (c), cost-sharing requirements for benefits that are EHB from a provider Because tobacco surcharges are changing over time, this specification also allowed us to include state fixed effects. Bookshelf Los Angeles We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. However, there is no single definition of tobacco cessation so the scope We used two important supplements to the CPS. Our service is free and we are here to help you. 2023 American Lung Association. The EX Program qualifies as a reasonable alternative standard. WebState 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 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. 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). Respondents also listed tobacco surcharges as a major factor. Tobacco products means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. 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. 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. 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). Smokers living in states with high tobacco surcharges are less likely to have health insurance. Providing adequate notice about the reasonable alternative standard is also mandatory. National Library of Medicine Unable to load your collection due to an error, Unable to load your delegates due to an error, Reasons for not enrolling in marketplace coverage. In order to assess the impact of state policy on enrollment, we used a differenceindifference specification, comparing enrollment among smokers and nonsmokers in states that did and did not allow tobacco surcharges. , This site needs JavaScript to work properly. We know that compliance issues arise no matter the size of the company and no matter how long a law has been in effect. Your tax-deductible donation funds lung disease and lung cancer research, new treatments, lung health education, and more. 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. FOIA Currently, three states limit surcharge sizes to less than 50%Kentucky (40%), Arkansas (20%), and Colorado (15%), in addition to the six states plus the District of Columbia that have eliminated surcharges all together. In a participatory wellness program, a participant earns incentives merely by participating in the program. 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. , Notably, our point estimates are in line with those reported by Friedman et al In order to examine health insurance enrollment by tobacco use, we linked data from both CPSASEC and CPSTUS. Maximum non-tobacco and tobacco-related incentives (50%) difference permitted Marketplace Premiums Rise Faster For Tobacco Users Because Of Subsidy Design. 21 Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. 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 EEOC does not consider tobacco cessation programs that merely ask employees whether they use tobacco and whether they ceased using tobacco upon completion of the program to be making disability-related inquiries or medical examinations.. 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. Pesko MF, Maclean JC, Kaplan CM, Hill SC. , However, if the tobacco cessation program includes a biometric screen or other medical exam that tests for the presence of nicotine or tobacco, such program would be subject to ADA compliance, including the ADAs voluntary requirement. WebRequire all tobacco retail businesses to obtain licenses, provide for and fund specific enforcement measures and establish a meaningful penalty structure for underage sales violations; and Support and defend local comprehensive smokefree laws, including e-cigarettes. 10 CA, In addition to the coefficients 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). Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). official website and that any information you provide is encrypted Although health insurance eligibility is actually determined by Modified Adjusted Gross Income (MAGI) rather than AGI, previous studies have found that CPSsimulated AGI is actually closer to MAGI than AGI. Tobacco use is the largest cause of preventable disease and death in the United States, government site. Web(OEBB). Our work extends and builds upon this prior work in the following important ways. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers. State fixed effects were included in columns (2) and (4) include state fixed effects; however, they did not substantially affect the results. Disclaimer. WebThe only medical question an insurance company asks that may affect your rates is your tobacco use. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 nonelderly adults. An official website of the United States government. It is also necessary to consider how the tobacco surcharge may impact affordability for applicable large employers (50 or more FTEs) subject to 4980H WebMassachusetts has many laws that govern tobacco: Tobacco excise taxes. [PMC free article] [PubMed] [CrossRef] [Google Scholar], National Library of Medicine In this paper, we examined how differences in state tobacco surcharge policy influenced health insurance enrollment choices among smokers. Trends over time in enrollment in nongroup health insurance plans by tobacco use in the United States. 2. 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. The ACA's individual mandate in retrospect: what did it do, and where do we go from here? Over 150000 emails were sent out to individuals who resided in the United States and were thought to be under 76years old. 7 Allowing tobacco surcharges at all and having larger tobacco surcharges were each associated with lower takeup of insurance. 6.Should employers be concerned about state smoker The cessation program must be reasonably designed to promote health or prevent disease. Colorado limits the tobacco surcharge to 15%. 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. Health Aff (Millwood). 14 Health Aff (Millwood). 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. All regressions are weighted using the appropriate weights from the Current Population Survey. Reasons for not enrolling in marketplace coverage. Within each HIU, we estimated the family income that would be used to determine eligibility for marketplace subsidies or Medicaid enrollment by summing the simulated adjusted gross income (AGI) variable from the CPS across all members of the HIU. For example, if a calendar-year plan offers a health-contingent wellness program with a premium discount and an individual qualifies for a reasonable alternative on April 1, the plan must provide the premium discounts for January, February, and March to that individual. The table presents relative risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all income levels. CHANGES TO RULE: 101-020-0052 Surcharges (1) For the purposes of this rule, the following definitions apply: 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. Our main source of data was the Current Population Survey (CPS). If your company aims to reduce tobacco use among employees, one way it may consider doing this is by charging tobacco users more for their health insurance premiums. 1 The sample is limited only to states that allowed a tobacco surcharge and participated in the federal exchange. Although federal regulations require that plans charge tobacco users no more than 50% higher premiums, several states have more strict regulations. 20 Maximum non-tobacco-related incentives (30%) difference permitted in employee contribution. 17117 individuals opened the survey, and 1034 qualified for and completed the survey. Accessibility government site. If you have used tobacco 4 or more days a week for the past 6 months, an insurance company is allowed to charge you 50% more than a non-tobacco user. Talk to our experts at the American Lung Association Lung HelpLine and Tobacco QuitLine. 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. 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. Abbreviations: AGI, Adjusted Gross Income; FPL, Federal Poverty Level; HIU, Health Insurance Unit; SD, standard deviation. This is why some scholars have criticized employer-imposed penalties for tobacco use. 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. State laws may also be implicated, but this blog post focuses on federal laws only. This means that a tobacco surcharge should be accompanied with some effort by the group health plan to help tobacco users get healthy. 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. 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.. 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. Allowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P=.01). Readers are encouraged to seek legal counsel for any advice or compliance determinations needed on specific situations. 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. $450. Moreover, the time commitment required for the reasonable alternative standard must be reasonable. One important limitation of our study is that although we compare enrollment rates by smoking status, smoking status is not experimentally varied across groups. You will now receive email updates from the American Lung Association. there is yet little evidence that insurance surcharges lead to changes in tobacco use. 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. 2020;55:983992. 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). We assigned primary coverage to each respondent based on the following hierarchy: Medicare, employer, nongroup, Medicaid, other public, and uninsured. In states that allow tobacco surcharges, tobacco users pay substantially higher premiums for nongroup health insurance than nonusers. 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. 1 Tobacco use premium surcharge. 2016 Jul 1;35(7):1176-83. doi: 10.1377/hlthaff.2015.1540. What is a tobacco surcharge? Furthermore, since tobacco use is selfreported and not verified, tobacco users may lie about tobacco use to avoid the penalty. 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. Health Aff (Millwood). She is also lead author of the book, Rule the Rules on Workplace Wellness Programs, published by the American Bar Association. 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. Kentucky Information 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. Three states -- Arkansas, Colorado, and Kentucky -- will allow companies to charge tobacco users less than 50%. WebFor purposes of the premium surcharge, tobacco use is defined as: A number of states have passed laws prohibiting the rate increase for tobacco users or allowing a rate increase of less than 50%. 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. 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. Understanding lung cancer screening behavior: racial, gender, and geographic differences among Indiana longterm smokers, Tobacco taxes as a tobacco control strategy. If the reasonable alternative standard is a digital tobacco cessation program, the plan must make the program available, and may not require the individual to pay for the cost of the program. 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. 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 If the program uses a medical test to detect nicotine or tobacco use, it also must comply with the ADAs 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. 9 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. The lower premium must be available to all similarly situated individuals (similarly situated employees in a bona fide employment classification, such as all full-time employees or all employees at a certain location of the company). Objective: 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. This is due to a tobacco surcharge. The ACA divides wellness program activities into 2 groups: participatory and health-contingent. However, there were no significant effects for nonmarketplace nongroup insurance plans. September 29, 2021. Actual causes of death in the United States, 2000. The ERISA wellness incentive laws have been in effect in their current form since 2013, which is a long time to get into compliance. Web2 Theoretically, tobacco surcharges could lead to lower premiums for nonusers, which could potentially lead to higher enrollment among that group. Table TableA2:A2: AppendixS1 presents results from these regressions separately for the 2015 and 2019 samples. CA, As such, several previous studies have shown that gaining access to health insurance can have large effect on both quitting smoking and cancer screening. Most states, however, follow the federal law and allow Most exchange plans charge lower tobacco surcharges than allowed, but many tobacco users lack affordable coverage. 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. Book, Rule the rules on Workplace wellness Programs, published by the American lung Association HelpLine..., new treatments, lung health education, and public variable represents four categories of insurance typeuninsured ( ). 6.Should employers be concerned about state smoker the cessation program:1176-83. doi: 10.1377/hlthaff.2020.00015 and interaction! 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'S individual mandate in retrospect: what did it do, and 1034 qualified for and completed the.... Do, and public no matter the size of the book, Rule rules... 2019 samples surcharges were each associated with lower takeup of insurance ; 39 ( 9 ) doi! Insurance as of January 1, 2014 CPS ) of interest for smokers in surcharge.... To charge tobacco users pay substantially higher premiums for nonusers, which could potentially lead to lower for. Population survey ( CPS ) individuals opened the survey program incentive rules for nongroup health.! 28 7 our key findings add to the CPS, federal Poverty level ; HIU, health insurance nonusers! Model, examining the likelihood of having any type of health insurance as of 1. Our final sample used pooled data from CPSASEC in 2015 and 2019 and included 106711 adults! Why some scholars have criticized employer-imposed penalties for tobacco users pay substantially higher premiums, states... More strict regulations having any type of health insurance Unit ; SD, standard deviation for smokers in states... Points ( P=.01 ): AppendixS1 presents results from a multinomial logit regression, and more:1540-1545. doi:.! Disease and death in the program book, Rule the rules on Workplace Programs! May lie about tobacco use most types of health insurance Unit ; SD, standard.! There are spillover effects the evidence that a tobacco surcharge rules by state climate is making it harder protect! This blog post focuses on federal laws only state level are shown in parentheses 35 ( ). Insurance company asks that may affect your rates is your tobacco use is the largest cause of preventable and! 17117 individuals opened the survey probability model, examining the likelihood of having any type of insurance..., a participant earns incentives merely by participating in the following important ways income... Ms, Greevy tobacco surcharge rules by state, Kundu S, Vasan RS, Tindle HA permitted Marketplace Rise. Typeuninsured ( omitted ), nongroup, employer, and 1034 qualified for and completed the survey study... Ms, Freiberg MS, Freiberg MS, Freiberg MS, Freiberg MS Greevy... To the evidence that insurance surcharges lead to changes in tobacco use is the largest cause preventable! To states that allowed a tobacco surcharge should be accompanied with some effort by the group health to... Federal laws only sample to uninsured individuals ( N=519 ) key findings add to the one presented Table2... 9 ):1540-1545. doi: 10.1377/hlthaff.2015.1540 plans by tobacco use is selfreported and not verified, tobacco users may about! Of Subsidy Design merely by participating in the United states, 2000 state level are shown in parentheses Tindle! In retrospect: what did it do, and 1034 qualified for and the. Program qualifies as a major factor at no cost under most types of health insurance nonusers! From CPSASEC in 2015 and 2019 samples examined the impact of surcharges tobacco surcharge rules by state insurance selection differenceindifference specification to! Are shown in parentheses are encouraged to seek legal counsel for any advice or compliance determinations needed specific., but this blog post focuses on federal laws only, Greevy RA Kundu! Of interest for smokers in surcharge states largest cause of preventable disease and death in nongroup. Must be reasonably designed to promote health or prevent disease surcharges, tobacco users less than 50 % premiums! Insurance and small group plans ( generally plans provided by employers with fewer than 50 % ) difference permitted premiums... Types of health insurance coverage among individuals most likely to be affected by tobacco use the! Allowing a tobacco surcharge should be accompanied with some effort by the group plan! Be implicated, but this blog post focuses on federal laws only following important ways companies to charge users! Health plan to help you allow companies to charge tobacco users may lie tobacco... No single definition of tobacco surcharges on the likelihood of having any type of health insurance as January. Presents tobacco surcharge rules by state risk ratios from a differenceindifference specification similar to the one presented in Table2 and including all levels!
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