1. Tobacco Cessation Coverage
From an insurance company perspective

2. Overview What is a comprehensive cessation benefit?
What coverage is required?
Next Steps
This is what I am going to tell you today

3. What is a Comprehensive Cessation Benefit?
Start with this, so we are all on the same page.

4. Comprehensive Benefit
Cessation Coverage
Comprehensive Benefit
7 Medications
5 NRTs (Gum, Patch, Lozenge, Nasal Spray, Inhaler)
Bupropion
Varenicline
3 Types of Counseling
Individual (face-to-face)
Group
Phone
Defined by: Treating Tobacco Use and Dependence: 2008 Update

5. Common Barriers to Access Care
Cessation Coverage
Common Barriers to Access Care
Cost Sharing (Co-Pays)
Prior Authorization
Stepped Care Therapy
Required Counseling
Duration Limits
Annual (or Lifetime) Limits
Dollar Limits
These are the common barriers.

6. Overview of key components: How the Affordable Care Act (ACA) expands tobacco cessation coverage

7. Increased Coverage Key ACA Components
Pre- ACA
19.2 Million People – Have Health Coverage
2010 NHIS data shows Uninsured people smoke at a higher rate than those with private health insurance (32.4% vs 16.%)
Medicaid expansion population smokes at a high rate, some states as high as 53%
Uninsured
Standard Medicaid
Private Insurance
Post – ACA
Uninsured
Standard Medicaid + Medicaid expansion
The NHIS Numbers - page 89 (
Key Points –
ACA increased coverage (visual depiction is a vast exaggeration) also – only showing under 65.
The newly covered group smokes at a higher rate, are less likely to be able to pay for cessation treatments on their own and are less likely to successfully overcome barriers to access
Private Insurance + Exchange with Premium Subsidies

8. Tobacco Cessation and ACA
Key ACA Components
Tobacco Cessation and ACA
Coverage Improvements
Created more options for health coverage for those with pre-existing conditions
Requires most plans to cover preventive services at no cost
Created the Prevention and Public Health Fund
Defined by: Treating Tobacco Use and Dependence: 2008 Update

9. Limits on Reach Key ACA Components
June United State Supreme Court struck down enforcement mechanism for Medicaid expansion, making it optional for states
Implementation of the law has not been even across the country
Trump Administration and Congress have repeatedly tried to repeal and weaken the law.
Defined by: Treating Tobacco Use and Dependence: 2008 Update

10. (Affordable Care Act Requirements)
What is Covered?
(Affordable Care Act Requirements)

11. Standard Medicaid

12. Medicaid – Pregnant Women
Cessation Coverage
Medicaid – Pregnant Women
2010 ACA requirement
All pregnant women on Medicaid have access to all treatments with no cost sharing.
Written into the Law- ACA Section 4107
Includes all FDA-approved pharmacotherapy and counseling
Smoking is linked to low birth weight and premature babies
Secondhand smoke is linked to SIDS
ACA Section 4107
Note: States needed to submit a state plan amendment

13. Standard Medicaid – Medications Requirement
Cessation Coverage
Standard Medicaid – Medications Requirement
Section 2502 of the Affordable Care Act removed tobacco cessation medications from the exclusions list.
Counseling not addressed.
Many States are still not covering all 7 FDA-approved medications.
Allows states to still charge a co-pay. .

14. Medicaid Expansion and Private Insurance

15. ACA Preventive Services Requirements
Cessation Coverage
ACA Preventive Services Requirements
This Requirement
Almost all private plans
Plans sold in the exchanges
Small group plans
Individual plans
Medicaid expansion plans
Difference Requirements
Medicare
Standard Medicaid Plans
Grandfathered Plans
Sixty-three percent of covered workers are in a plan that is completely or partially self-funded
In 2000 it was 49%
National plans now offering self-insured products for groups as small as 50 employees
Regulation varies – State Insurance comm
3rd party administration – ASO (Administrative Services Only)

16. Types of Health Coverage
Essential Health Benefits
ACA requires most plans to cover a minimum set of benefits: the Essential Health Benefits(EHB). The types of plans include: Private Plans, Exchange plans and Medicaid expansion plans.
Includes the Preventive Services requirement.

17. ACA Preventive Service Requirement
Cessation Coverage
ACA Preventive Service Requirement
ACA requires most private plans, including any plan sold on the exchange and Medicaid Expansion plans, to cover without cost-sharing all services given an ‘A’ or ‘B’ grade by United States Preventive Services Task Force (USPSTF).
Tobacco Cessation receives an ‘A’ grade
The ACA says all preventive services graded A or B by the USPSTF must be covered in most insurance products without any cost to the patient.
I say most insurance products because some products are still grandfathered in and don’t have to comply with this component of the ACA. This requirement applies to Medicaid expansion and most private insurance.
Tobacco cessation was rated A.
It was initially unclear how this rating was to be translated into insurance coverage
But there has now been two clarifications or updates to this initial rating…..

18. Key ACA Components – Cessation Coverage
Cessation Guidance FAQ
On May 2, 2014 the Departments of Labor, Treasury and Health and Human Services issues a FAQ questions on how the tobacco cessation recommendation should be implemented.
Tobacco Cessation Guidance
At least 4 sessions of individual, group and phone counseling
At least 90 days of all FDA-approved smoking cessation medications, when prescribed
At least 2 quit attempts per year
No cost-sharing
No prior authorization
USPSTF is important, but it provides clinical recommendations, not policy.
The FAQ is supposed to act like a bridge, translating the clinical recommendation into insurance policy. There are a few loopholes in the current FAQ that the insurance companies are unfortunately exploiting.
Enforced by: State Health Insurance Commissioners, the Department of Labor and CMS
12 state Insurance Commissioners have taken action by either issuing a bulletin or consumer alert
Ensures enforcement at state level, even if no enforcement at federal level
The Lung Association along with our partners, including CWMN, sent a letter to the tri secretaries asking for a new FAQ removing the “for example” language, clarifying that plans need to provide all meds and counseling without cost sharing Q5

19. Key ACA Components - Cessation Coverage
September 2015 USPSTF Updated Cessation Recommendation
In September 2015, the USPSTF updated their recommendation, reaffirming the “A” grade for tobacco cessation.
Found that both counseling and pharmacotherapy are effective to help smokers quit.
States are responsible for implementation for private plans.
In fall of 2015 the USPSTF updated the cessation interventions recommendation itself, clarifying that all types of counseling and all FDA-approved medications are included. Most health insurance products beginning after October 1, 2016 must comply with the updated rating.
This updated rating, coupled with the FAQ, gives states, insurance companies and consumers a clear idea of what should be covered.

20. What does it mean? Cessation Coverage
Studies have suggested that many private plans in the exchanges are not covering all cessation treatments and in some cases are imposing cost- sharing and other barriers.
Information on coverage is often conflicting and confusing
Some states are reaching out to large private employers to improve coverage.
Some states have reached out to their Insurance Commissioner to ask for a bulletin or consumer alert clarifying what needs to be covered.

21. Questions? Anne DiGiulio, Anne.DiGiulio@Lung.org 202-785-3355