Coverage for Tobacco Use Cessation Treatments

Tobacco Use Imposes a Major Health and Economic Burden
clip art with money hovering over left hand and heart with medical symbol over right hand

Tobacco use is the leading cause of preventable disease and death in the United States.1,2  Every year, smoking kills approximately 480,000 Americans and costs the nation more than $300 billion a year, including nearly $170 billion in direct medical care and more than $156 billion in lost productivity, imposing a heavy economic burden on employers, health plans, and federal, state, and local governments.1,2,3

Quitting smoking considerably reduces health risks. Smoking cessation improves well-being, including higher quality of life and improved health status, and reduces the risk of premature death.1

Effective Cessation Treatments Are Available

The 2020 Surgeon General’s Report on Smoking Cessation concluded that:

  • Smoking cessation medications approved by the federal Food and Drug Administration (FDA) and behavioral counseling are cost-effective cessation strategies.1 FDA-approved cessation medications and behavioral counseling increase the likelihood of successfully quitting smoking, particularly when used in combination.1
patch and gum
  • Using combinations of nicotine replacement thera­pies (NRT) can further increase the likelihood of quitting.1 Specifically, combining short-acting (e.g., nicotine gum or the nicotine lozenge) and long-acting (the nicotine patch) forms of NRT increases smoking cessation compared with using single forms of NRT.1
  • Proactive quit­line counseling (counseling delivered through multiple outbound calls), when provided alone or in combina­tion with cessation medications, increases smoking cessation.1 Tobacco quit­lines are an effective population-based approach to motivate quit attempts and increase smoking cessation.1 Publicly supported quitlines are available in all states, the District of Columbia, Guam, and Puerto Rico and can be accessed anywhere in the United States by calling 1-800-QUIT-NOW.1
  • Short text message services about cessation are independently effective in increasing smoking cessation, particu­larly if they are interactive or tailored to individual text responses.1
  • Web or Internet-based interventions increase smoking cessation and can be more effective when they contain behavior change techniques and interactive components.1

The 2008 Public Health Service (PHS) Clinical Practice Guideline on Treating Tobacco Use and Dependence concluded that:

  • Tobacco dependence is a chronic disease.4 Most adults who smoke make multiple quit attempts before succeeding.4 Many adults who smoke require repeated cessation interventions.4
  • Effective cessation treatments include individual, group, and telephone counseling and seven FDA-approved medications.4
  • Even brief cessation advice and counseling by health care providers is effective, and should be offered to every patient.4
doctor discussing medication with patient
  • The effectiveness of cessation counseling increases with the intensity of the counseling, including the length and number of counseling sessions.4
  • The seven FDA-approved medications include five forms of NRT: the patch, gum, inhaler, nasal spray, and lozenge; as well as two non-NRT medications, bupropion SR (brand name Zyban®), and varenicline (brand name Chantix®).4
  • Three forms of NRT—the patch, gum, and the lozenge—are available without a prescription from a health care provider. The other two forms of NRT (the inhaler and the nasal spray), as well as the two non-NRT medications, are available by prescription only. The patch is available both by prescription and over the counter.4
  • Quit rates increase when clinicians and health care providers consistently identify and treat patient  tobacco use.4
Cessation Treatments Are Underused
  • Proven cessation treatments are underused by adults who smoke.1,4,5
  • About 7 in 10 U.S. adults who smoke want to quit, and just over half try to quit each year.1,5,6
  • However, fewer than 1 in 10 U.S. adults who smoke succeeds in quitting each year, in part because fewer than one-third of adults who try to quit smoking use proven cessation treatments.1,5,6
  • In 2015, about 3 in 5 (57.2%) adults who smoke and who saw a health professional in the past year reported receiving advice to quit.1,5
Insurance Coverage of Cessation Treatments Increases Their Use
  • Insurance coverage for smoking cessation treat­ment that is comprehensive, barrier-free, and widely promoted increases the use of these treatment ser­vices and leads to higher rates of successful quitting.1
Insurance Coverage of Cessation Treatments Is Cost-Effective
piggy bank with money and calculator
  • Smoking ces­sation interventions are cost-effective.1,4
  • Insurance coverage for smoking cessation treat­ment that is comprehensive, barrier-free, and widely promoted is cost-effective.1
  • Cessation treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders.4
  • Cost-effectiveness analyses have shown that tobacco dependence treatment compares favorably with routinely reimbursed medical interventions such as treatment for high blood pressure and high cholesterol, as well as preventive screening interventions such as periodic mammography or Pap tests.4
Best Practices for Designing Cessation Coverage Benefits

Comprehensive Insurance Coverage for Tobacco

  • Covers all evidence-based cessation treatments, including counseling and both over-the-counter and prescription medications.1,4,7,8
  • Eliminates or minimizes barriers to accessing these treatments.1,4,7,8,9
  • Is promoted to tobacco users and health care providers, and includes monitoring coverage use, because high use is essential for a cessation benefit to have its intended effect.1,4,8,10
Man and woman reviewing paperwork in front of laptop

Specifically, comprehensive cessation coverage includes the following:4

  • Covers individual, group, and telephone counseling.
  • Covers all FDA-approved cessation medications and any future medications approved for this purpose by the FDA.
  • Covers at least two quit attempts per year.
  • Covers at least four counseling sessions of at least 10 minutes each per quit attempt.

Eliminating Barriers

  • Reducing out-of-pocket costs for evidence-based cessation treatments increases use of these treatments and increases the number of tobacco users who quit.4,9
  • Effective cessation coverage eliminates or minimizes barriers to accessing cessation treatments such as copayments, coinsurance, deductibles, annual or lifetime dollar limits, and prior authorization.1,4,7,8,9

Promoting Coverage and Monitoring its Use

  • Another important barrier to using evidence-based cessation treatments is lack of awareness among tobacco users and providers that specific health plans cover such treatments.1,10,11
  • Lack of awareness of cessation insurance coverage translates into low use of cessation treatments.1,10,11
  • High use of a cessation benefit is essential for it to be effective—even a comprehensive cessation benefit will not be effective if it goes unused.1,10,11
  • Accordingly, it is important to monitor use of a cessation benefit, for example by tracking use of counseling and medications and performance on cessation quality measures.1,8,10,11
  • Promotion of a tobacco cessation benefit is also affected by the benefit design. It is easier to promote standard, comprehensive coverage.11 If coverage varies widely, it is more difficult for providers and patients to understand what is covered for any given patient.11
Current Status of Cessation Coverage

Private Insurance

  • As of September 23, 2010, Section 1001 of the Patient Protection and Affordable Care Act required most private health plans, including all plans sold in the federal or state exchanges, to cover, with no cost-sharing when provided in-network, clinical preventive services that have received an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF). For adults, this includes tobacco cessation interventions, which have an “A” rating. The USPSTF recommendations do not spell out the specifics of recommended cessation interventions.
  • On May 2, 2014, the Department of Health and Human Services, together with the Departments of Labor and Treasury, issued the following subregulatory guidance on this provision.12

“The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. What are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions?

As stated earlier, plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance for plans and issuers. The Departments will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost-sharing:

  1. Screening for tobacco use; and,
  2. For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:
  • Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and
  • All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update.”

As of January 1, 2020, 16 states (Colorado, Delaware, Illinois, Kentucky, Louisiana, Maryland, Massachusetts, New Jersey, New Mexico, New York, North Dakota, Oregon, Pennsylvania, Rhode Island, Utah, and Vermont) have laws or regulations in place requiring at least some private insurance plans to cover certain cessation treatments. Specific provisions vary from state to state.13,14

Medicaid

Under Section 1905(a)(4)(D) of the Social Security Act (as amended by the Patient Protection and Affordable Care Act), all state Medicaid programs are required to provide a comprehensive tobacco cessation benefit as defined by the U.S. Public Health Service guideline to pregnant women who are enrolled in Medicaid.15

As of January 2014, Section 1927 of the Social Security Act bars state Medicaid programs from excluding cessation medications, including over-the-counter medications, from coverage.16

States may choose to expand Medicaid coverage to enrollees with incomes up to 138% of the federal poverty level, pursuant to the Affordable Care Act.17 Under Section 1905(a)(13)(A) of the Social Security Act, benefits for these “expanded Medicaid” enrollees must include clinical preventive services that have received an “A” or “B” recommendation from the USPSTF, which must not be subject to cost-sharing.17 These preventive services include tobacco cessation interventions.18

Cessation coverage for Medicaid enrollees varies by state.19 All states cover at least some cessation treatments for all Medicaid enrollees.19

The Centers for Medicare and Medicaid Services allows states to claim a 50% match for the cost of counseling provided to Medicaid enrollees by state tobacco quitlines that follow evidence-based guidelines.20

Medicare

Medicare beneficiaries have access to individual cessation counseling21 and prescription cessation medications.22 The benefit covers two quit attempts a year and four counseling sessions per quit attempt.21 Medicare copayment, coinsurance, and deductibles for cessation counseling are waived.21

Federal Employees

Since January 2011, the Office of Personnel Management (OPM) has required all Federal Employees Health Benefits (FEHB) carriers to offer tobacco cessation programs to all covered individuals without copayments or coinsurance and which are not subject to deductibles, or to annual or lifetime dollar limits.7 Programs must follow the most current USPSTF recommendations by covering at least two quit attempts per year with each attempt allowing a minimum of four tobacco cessation counseling sessions, including individual counseling, group counseling, and proactive telephone counseling.7 Carriers are advised that the FEHB tobacco cessation benefit includes coverage of cessation treatment for users of all tobacco products, including e-cigarettes.7 In addition to the tobacco cessation counseling programs, OPM requires cessation medications (over-the-counter and prescribed) approved by the FDA to treat tobacco dependence to be available with no copayments or coinsurance and not subject to deductibles or to annual or lifetime dollar limits.7

State Employees

Cessation coverage varies by state. As of January 1, 2020, six states (Delaware, Iowa, Minnesota, Missouri, New Hampshire, and North Dakota) cover all three forms of evidence-based cessation counseling and all seven FDA-approved cessation medications for state employees and their dependents.13,14

Active-Duty Military Service Members

Tobacco cessation counseling is covered for all TRICARE beneficiaries aged 18 years or older who are not Medicare-eligible and who reside and receive counseling in 1of the 50 United States or the District of Columbia.23 Counseling sessions must be conducted by a TRICARE-authorized provider.23

Covered tobacco cessation products are available in the United States for all TRICARE beneficiaries aged 18 years or older who are not eligible for Medicare.23 Overseas, the products are available to active duty service members and their dependents (who are enrolled in TRICARE Overseas Program Prime) at military pharmacies and through home delivery (where available), including the U.S. territories of Guam, Puerto Rico, and the U.S. Virgin Islands.23

All seven FDA-approved tobacco cessation products are available at no cost through military pharmacies and TRICARE Pharmacy Home Delivery.23

Military Service members should check with their TRICARE Regional Contractor for additional tobacco cessation services and programs that may be available.23

Case Studies

Massachusetts Medicaid Cessation Benefit

The state of Massachusetts offered a nearly comprehensive cessation benefit to Medicaid enrollees in 2006.8 The benefit provided up to two 90-day courses per year of FDA-approved cessation medications, including over-the-counter NRT, and up to 16 individual or group counseling sessions.8 Enrollees needed prescriptions to obtain medications, and prior authorization was required to obtain the nicotine inhaler and nicotine nasal spray.8 Copayments of $1 or $3 were charged.8 The benefit was heavily promoted to providers through extensive materials distribution and outreach and to Medicaid enrollees through targeted radio, transit, and Internet ads, posters, brochures, and a Medicaid mailing.8 In the first 2 ½ years post implementation, 37% of Massachusetts Medicaid enrollees who smoked­—more than 70,000 people—used the benefit.8 The smoking rate in the Massachusetts Medicaid population fell from 38% to 28% over a 2 ½-year period.8 Finally, annualized hospitalizations for heart attacks and other acute heart disease diagnoses among Medicaid enrollees who used the benefit fell by almost 50%,24 and every dollar spent on the benefit was associated with $3.12 in medical savings for cardiovascular conditions.25

Office of Personnel Management Cessation Benefit for Federal Employees

Starting in January 2011, the U.S. Office of Personnel Management (OPM) has provided a comprehensive cessation benefit for federal employees, retirees, and their families.7 Carriers must offer tobacco cessation programs to all covered individuals without copayments or coinsurance, and which are not subject to deductibles, or to annual or lifetime dollar limits.7 Programs must follow the most current USPSTF recommendations by covering at least two quit attempts per year with each attempt allowing a minimum of four tobacco cessation counseling sessions, including individual counseling, group counseling, and proactive telephone counseling.7 Carriers are advised that the FEHB tobacco cessation benefit includes coverage of cessation treatment for users of all tobacco products, including e-cigarettes.7 In addition to the tobacco cessation counseling programs, OPM requires cessation medications (over-the-counter and prescribed) approved by the FDA to treat tobacco dependence to be available with no copayments or coinsurance and not subject to deductibles or to annual or lifetime dollar limits.7

References
  1. S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020. https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/index.html. Accessed July 15, 2020.
  2. S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2014. https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm. Accessed July 15, 2020.
  3. Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual healthcare spending attributable to cigarette smoking: an update. Am J Prev Med. 2015;48:326–333.
  4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2008. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.htmlexternal icon. Accessed June 4, 2020.
  5. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting smoking among adults—United States, 2000–2015. MMWR Morb Mortal Wkly Rep. 2017;65(52):1457–1464. https://www.cdc.gov/mmwr/volumes/65/wr/mm6552a1.htm?s_cid=mm6552a1_w. Accessed June 4, 2020.
  6. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators among adults—United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68:1013–9. https://www.cdc.gov/mmwr/volumes/68/wr/mm6845a2.htm?s_cid=mm6845a2_w. Accessed June 4, 2020.
  7. U.S. Office of Personnel Management. Special Initiatives: Quit Smoking website. Accessed June 4, 2020.
  8. Land T, Warner D, Paskowsky M, et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS ONE. 2010;5(3):e9770. doi:10.1371/journal.pone.0009770.
  9. Community Guide Task Force on Community Preventive Services. Reducing Tobacco Use and Secondhand Smoke Exposure: Reducing Out-of-Pocket Costs for Evidence-Based Cessation Treatments website. http://www.thecommunityguide.org/tobacco/outofpocketcosts.htmlexternal icon. Accessed July 15, 2020.
  10. Keller PA, Christiansen B, Kim S-Y, et al. Increasing consumer demand among Medicaid enrollees for tobacco dependence treatment: the Wisconsin “Medicaid covers it” campaign. Am J Health Promot. 2011;25(6):392–395. DOI: 10.4278/ajhp.090923-QUAN-311.
  11. American Lung Association. Approaches to Promoting Medicaid Tobacco Cessation Coverage: Promising Practices and Lessons Learned. Washington, DC: American Lung Association; 2016. https://www.lung.org/getmedia/95de6301-698b-495b-bbad-fce35a8181ca/promoting-medicaid-tobacco-cessation.pdf pdf icon[PDF – 1.6 MB]external icon. Accessed June 4, 2020.
  12. Centers for Medicare and Medicaid Services. FAQS About the Affordable Care Act Implementation Part XIX website (see Q5). https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs19external icon. Accessed June 4, 2020.
  13. American Lung Association. State Tobacco Cessation Coverage Database.
  14. American Lung Association. State of Tobacco Control Report 2020. Washington, DC: American Lung Association; 2020.
  15. Section 1905(a)(4)(D) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act, Pub. L. 111–48 124 Stat. 560, March 23, 2010, as amended through May 1, 2010. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf pdf icon[PDF – 2.5 MB]external icon. Accessed June 4, 2020.  The Centers for Medicare & Medicaid Services has issued guidance to states on implementing this provision. https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD11-007.pdf pdf icon[PDF – 273 KB]external icon. Accessed June 4, 2020.
  16. Section 1927 of the Social Security Act, as amended by the Patient Protection and Affordable Care Act, Pub. L. 114–48 124 Stat. 310, March 23, 2010, as amended through May 1, 2010. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf pdf icon[PDF – 2.5 MB]external icon. Accessed June 4, 2020. The Centers for Medicare & Medicaid Services has issued guidance to states on implementing this provision. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Prescription-Drugs/Downloads/Rx-Releases/State-Releases/state-rel-165.pdf pdf icon[PDF – 130 KB]external icon. Accessed June 4, 2020.
  17. Section 1905(a)(13)(A) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act. http://housedocs.house.gov/energycommerce/ppacacon.pdf pdf icon[PDF – 2.6 MB]external icon. Accessed June 4, 2020.
  18. Siu AL; US Preventive Services Task Force. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163:622–634. Accessed June 4, 2020.
  19. Centers for Disease Control and Prevention. State Medicaid coverage for tobacco cessation treatments and barriers to accessing treatments—United States, 2008–2018. MMWR Morb Mortal Wkly Rep. 2020;69(6):155–160. https://www.cdc.gov/mmwr/volumes/69/wr/mm6906a2.htm?s_cid=mm6906a2_w Accessed June 4, 2020.
  20. Centers for Medicare and Medicaid Services. State Medicaid Director Letter re: New Medicaid Tobacco Cessation Services; 2011. http://www.cms.gov/smdl/downloads/SMD11-007.pdf pdf icon[PDF – 273 KB]external icon. Accessed July 15, 2020.
  21. Centers for Medicare and Medicaid Services. Medicare and You. Baltimore, MD: US Department of Health and Human Services; 2020. https://www.medicare.gov/pubs/pdf/10050-medicare-and-you.pdf pdf icon[PDF – 3.1 MB]external icon. Accessed July 15, 2020.
  22. Centers for Medicare and Medicaid Services. Tobacco Prescription Drug Coverage website. https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovgenin/downloads/cms-4068-f3column.pdf pdf icon[PDF – 8.3 MB]external icon. Accessed July 15, 2020.
  23. Tobacco Cessation Program website. https://www.tricare.mil/CoveredServices/IsItCovered/TobaccoCessationServices.external icon Accessed July 15, 2020.
  24. Land T, Rigotti NA, Levy DE, et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Med. 2010;7(12):e1000375. doi:10.1371/journal.pmed.1000375.
  25. Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PLoS ONE. 2012;7(1):e29665. doi:10.1371/journal.pone.0029665.