Tobacco Use Attestation Form completion required
Human Resources Management at Mississippi State reminds all benefits-eligible employees that the Mississippi Department of Finance and Administration's board voted recently to implement a $50 per month tobacco use surcharge, effective July 2015, for the State and School Employees' Health Insurance Plan.
All plan participants are required to complete a "Tobacco Use Attestation Form," which will soon be mailed directly to participants' home address, or may be downloaded now from the DFA Web site at http://knowyourbenefits.dfa.state.ms.us -- click on "Tobacco Cessation Program." Detailed information and a question-and-answer section for participants are also available on the website.
The deadline for receipt of a completed Tobacco Use Attestation Form is May 1 at 5 p.m. Your MSU I.D. number -- not Social Security number -- should be submitted on the form.
Your "Tobacco Use Attestation Form" may now be completed and mailed to the Mississippi State University Department of Human Resources Management, Room 150, McArthur Hall or sent via Campus Mail to mail strop 9603.
The tobacco use surcharge is effective July 2015, and it will be charged to all plan participants who respond affirmatively as a tobacco user on the attestation form as well as to plan participants who fail to complete the attestation form by the May 1 deadline. The $50 per month will be charged in addition to the monthly premium.
Retirees and COBRA participants are also required to complete the attestation form. Dependents or spouse covered by plan participants are not affected by the surcharge and should not complete an attestation form.
The surcharge may be avoided for the first six months by agreeing to complete the plan's sponsored tobacco cessation program, as indicated on the attestation form. Completion of the cessation program is required in order to waive the surcharge. Enrollment in the plan's tobacco cessation program is required, and may be completed by calling ActiveHealth Management at 866-939-4721.
Details about the tobacco cessation program are available online at http://knowyourbenefits.dfa.state.ms.us -- click on Tobacco Cessation Program.
Participants who do not submit a completed form by the May 1 deadline will default to an affirmative tobacco user attestation and will be charged the $50 per month surcharge. Participants are encouraged to complete the form and submit it according to the instructions provided on the form.
All MSU plan participants will receive acknowledgement of a completed attestation form from the MSU Benefits Office within approximately two weeks of receipt of your attestation form. Plan participants who have not submitted an attestation form will be sent regular reminder notifications via email up to the May 1 deadline.
Thank you for your attention to this important matter. If you have questions or need additional information, you may contact the MSU Benefits Office at 662 325-3713, or the Department of Finance and Administration’s Office of Insurance at 601-359-3411 or toll-free 866-586-2781.
