"From a practical standpoint, the implementation of these smoking surcharges was almost non-existent for this first year of exchange enrollments because of technology constraints," he notes. "But they will almost certainly have an impact in the near future for those exchanges that didn't opt out of the smoking surcharge provision – including the federal exchange, which represents more than half of the states."

According to Michael Mahoney, the senior vice president of consumer marketing for GoHealth, the surcharges in the PPACA were part of a balancing act – the other side of which involved pre-existing conditions.

"There are two provisions to consider," he explains. "According to PPACA, people can no longer be denied insurance or charged more based on pre-existing conditions. But there's a flip side – you do want to use cost, especially premiums, as a method to incentivize healthy behavior. So there's a provision written into the PPACA that says you can charge more or less based on a modifiable behavior. So while you can't charge somebody more if they had a heart attack, you can charge them more if they smoke, because that's a modifiable behavior."

The focus so far, Mahoney says, has been on tobacco and obesity.

"Those are part of preventative services," he notes, "and primary care providers have to offer those anyway."

And just because carriers have the ability to impose a surcharge, he adds, does not indicate they will all exercise it.

"Insurance companies don't have to do this," he says, "but they can do this as a strategy to make their members healthier. So just because you smoke or don't smoke doesn't mean you'll be charged more or less – and if you participate in smoking cessation programs as a current smoker, you won't necessarily save money."

There is also the issue of how surcharges are set up in conjunction with wellness programs and other employer-based (or carrier-based) benefits.

"We all agree that health programs need to be meaningfully created to recognize that lifestyle is at least a partial determinant on the quality outcome," says Joe Torella, president of the HUB International Northeast Employee Benefits division and HUB International's Employee Benefits National Practice Leader. "There has always been this question of whether or not people who are smokers or who live a more dangerous lifestyle are indeed a worse risk. PPACA basically said, for the first time, we want to have meaningful wellness – we do believe the regulatory body should work more in concert with health care, and we should all recognize that if somebody is a smoker or making other decisions that undermine their health, those things should be taken into consideration.

"There's been a cautionary approach," Torella continues, "that says we don't want direct correlation between costs and these programs – but we want incentives for employers to create programs around wellness. We've got to have protection for employees; we need to be careful about renewability of policies and pre-existing conditions. However, we can agree that there are things people can do to be more careful of their health."

"As insurance companies face more pressure to control premiums as they pass on PPACA fees to employers, and with tighter constraints on their minimum loss ratios and margins, you can expect to see pressure for improving health and outcomes and they try to combat the rising costs," Haughey predicts. "The discussion will continue about what is a behavior and what is a condition to be surcharged – but, regardless, all those involved are going to be tasked with improving health outcomes and controlling costs.

"With any sea change, there are going to be winners and losers," he concludes. "The influence of PPACA is no different. Community-rated products are leveling out industry and age factors that help generate the required premiums, so as some industries and older employees will see their premiums go down, other preferred industries and younger employees will see their premiums go up."