Report on Cessation Coverage
Monday, November 26, 2012
Posted by: Natalia Gromov
The Campaign for Tobacco-Free Kids released a report on insurance coverage of
tobacco cessation services that was conducted by Georgetown University
performed a comprehensive analysis of 39 insurance contracts currently being
sold in six states. The report finds that many insurers are not covering
tobacco cessation treatments found to be effective by the U.S. Preventive
Services Task Force and required by the Affordable Care Act. Many
policies contain confusing and conflicting language that could leave consumers
uncertain if tobacco cessation treatments are covered. Many policies also
include significant gaps in coverage for cessation counseling and medications
and contain cost-sharing requirements that appear to conflict with the law.
press release and a link to the full report are provided below. PDF of the report can be found here.
IMMEDIATE RELEASE: November 26, 2012
Peter Hamm, 202-296-5469
Health Insurance Plans Fall Short in Covering Tobacco Cessation Treatments
Mandated by Health Reform Law, Study Finds
University Researchers Find Confusing Language and Coverage Gaps in Contracts
Many health insurance plans are failing to provide coverage mandated by the
health care reform law for treatments to help smokers and other tobacco users
quit, according to a study of insurance contracts by Georgetown University
researchers conducted for the Campaign for
Tobacco-Free Kids. The authors recommend that federal and state
regulators give insurers detailed guidance on what tobacco cessation coverage
is required under the landmark Affordable Care Act (ACA).
ACA requires all new private health insurance plans to cover preventive health
services recommended with an A or B grade by the U.S. Preventive Services Task
Force (USPSTF), with no cost-sharing such as co-pays. These
recommendations include tobacco cessation treatments, which received an A
grade. The USPSTF recommends that clinicians ask adults about tobacco use
and provide cessation interventions for tobacco users. It found that more
or longer counseling sessions improve quit rates and combining counseling with
medication is more effective for treating tobacco dependence than either
therapy used alone.
determine how the cessation coverage requirement is being implemented,
insurance experts at the Georgetown University Health Policy Institute analyzed
39 health insurance plans sold in six states, including individual, small
group, federal employee and state employee plans. The study was
commissioned by the Campaign for Tobacco-Free Kids with funding from Pfizer,
researchers found that many policies are rife with confusing and conflicting
language that could leave consumers uncertain if tobacco cessation treatments
are covered and discourage them from seeking these treatments. It also
found that many policies included gaps in coverage for cessation counseling and
medication and cost-sharing requirements that appear to conflict with the law.
36 contracts indicated that they covered tobacco cessation or are providing
coverage consistent with the USPSTF recommendations, 26 of these contracts also
included language entirely or partially excluding tobacco cessation from
coverage. For example, one contract states "preventive adult wellness
Services are covered… that have in effect a rating of ‘A’ or ‘B’ in the current
recommendations” of the USPSTF. The same contract, in the "what is not
covered” section, lists "Smoking Cessation Programs including any Service to
eliminate or reduce the dependency on, or addiction to, tobacco, including but
not limited to nicotine withdrawal programs and nicotine products (e.g., gum,
transdermal patches, etc.).”
was wide variation in coverage for cessation counseling and medication, raising
concern that treatments found to be effective by the USPSTF and required under
the ACA are not being covered. Only four of the 39 plans stated they covered
individual, group and phone counseling and both prescription and
over-the-counter (OTC) medications. Many policies specifically excluded
certain types of counseling and provided no coverage of prescription and OTC
medications for tobacco cessation.
apparent conflict with the law, some policies included cost-sharing
requirements. Seven of 36 contracts that clearly covered counseling required
cost-sharing for counseling by in-network providers, and six of 24 contracts
that covered prescription drugs required cost-sharing.
Affordable Care Act recognized that coverage for preventive care, including
helping people quit tobacco, is a critical part of improving health and
reducing health care costs in our country,” said Matthew L. Myers, President of
the Campaign for Tobacco-Free Kids. "Tobacco use is a leading risk factor for
cancer, heart and lung disease and other serious chronic conditions.
Covering effective tobacco cessation treatments is a smart way for insurers to
avoid the cost of future illness, and it is the law.”
is shocking to see the huge variation in what appears to be a straight forward
inexpensive benefit that has significant medical evidence on treatment that works,”
Mila Kofman, principal author of the report and former Maine Superintendent of
Insurance said, "It is even more disappointing to find that some in the
insurance industry are trying to avoid covering tobacco cessation treatment as
required by the Affordable Care Act.”
report made the following recommendations to federal and state regulators:
should require that health insurance policies include a clear statement that
tobacco cessation treatment is a covered benefit. Policies should specifically
state which treatments are covered and that cost-sharing does not apply.
should provide guidance on permissible and prohibited limitations to coverage
under the ACA.
regulators should provide model contract language for this benefit, which would
help address ambiguities and uncertainties over what benefits are available to
consumers and how to access such benefits.
issued by the U.S. Office of Personnel Management (OPM) for the Federal
Employees Health Benefits Program is an excellent model to help define the
scope of coverage required by the ACA. OPM instructed insurers to cover
tobacco cessation treatments without cost-sharing. Insurers must cover at
least two quit attempts per year with up to four cessation counseling sessions
of at least 30 minutes each (including individual, group and phone
counseling). They must also cover OTC and prescription medications.
detailed guidance, huge variations in benefits will continue to be a problem,
and tobacco users’ access to tobacco treatment will continue to be
limited. Finally, absent additional steps by federal or state regulators,
the promise of reducing tobacco use – saving lives and saving health care
resources – will not be realized fully,” the report concludes.
use is the leading cause of preventable death in the United States, killing
more than 400,000 Americans and costing the nation $96 billion annually in
direct medical costs.
study can be found at http://tfk.org/coveragereport/.
Source: Victoria Almquist, Director, Outreach, Campaign for