Tobacco Surcharge Physician Affidavit Form 2025

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Tobacco surchargesalso called quit-tobacco incentives or nonsmoker discountsare typically based on affidavits that employers collect during open enrollment. If an affidavit. indicates someone uses tobacco, that person pays a premium rate for their healthcare.
The Tobacco Attestation Form asks employees to attest and certify to their current use or lack of tobacco use.
A tobacco surcharge is a variation in insurance premiums based on an individuals tobacco use. The intention of tobacco surcharges is to incentivize tobacco use cessation, as well as to offset the higher healthcare costs attributed to smoking.
ing to the federal Department of Health and Human Services, insurance companies consider folks tobacco users if they use tobacco products including cigarettes, cigars, pipe tobacco, and chewing tobacco on average four or more times a week during the past six months.
This form is used to determine your premium rate. You are only eligible for the lower non-tobacco user rate after you can attest that you use tobacco products, on average, less than four (4) times per week for six (6) months or longer. By Mail: Chorus Community Health Plans.

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This is true, for example, even when a plan member is still using tobacco after the competition of a tobacco-cessation program. In order to avoid the tobacco surcharge, the plan member need only complete the RAS actually becoming a nonsmoker isnt required.

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