Despite ACA mandate, tobacco cessation not always covered

The Affordable Care Act decrees that insurers cover a list of preventive services, including smoking cessation attempts. But that doesn't mean physicians will always get paid for helping patients kick the habit.

“There's huge diversity in how this is being implemented,” said Mila Kofman, a research professor at Georgetown University's Health Policy Institute in Washington. “I would not assume that when a physician provides tobacco-cessation treatment that automatically the health plan will pay for it.”

Physicians may need to confirm with an insurer what is covered, she said.

Kofman analyzed 39 contracts between patients and insurers for individual, small group and government employee policies in six states. The report, funded by the Campaign for Tobacco-Free Kids, was issued Nov. 26.

Thirty-six contracts included language indicating that preventive services would be paid for in full, but 26 of those contracts said smoking cessation was not covered. Four contracts excluded individual counseling, and 10 didn't include telephone counseling. Seven covered counseling for tobacco cessation but required patients to pay a portion.

Other contracts limited access to tobacco cessation by requiring a related health condition before coverage would begin. The insurance companies in the study were not identified.

Researchers who study tobacco-cessation trends say that in some cases, part of a contract may have been changed to comply with health system reform legislation, while other parts went untouched. In some instances, insurers may pay for tobacco cessation that a physician recommends, despite what the contracts say.

Researchers say it may be difficult for insurers to translate clinical guidelines, such as U.S. Preventive Services Task Force recommendations, into insurance coverage decisions.

The task force calls on physicians to “ask all adults about tobacco use and provide tobacco-cessation interventions for those who use tobacco products.” But insurers may have different definitions of what that means.

“The language around smoking cessation as a covered benefit is extraordinarily confusing,” said Michael Fiore, MD, MPH, director of the Center for Tobacco Research and Intervention at the University of Wisconsin School of Medicine and Public Health in Madison.

Who pays for smoking cessation?

Researchers and the insurance industry are calling for more guidance on tobacco cessation from the Dept. of Health and Human Services. Defining smoking cessation is important, because helping people give up tobacco probably will become one of the essential health benefits required of most health plans, including benefits offered through a health insurance exchange, as of 2014.

“USPSTF recommendations are guidance for clinical practice, and there is likely a need for additional clarity as health plans apply these clinical recommendations to benefit design,” according to a statement from America's Health Insurance Plans issued Nov. 28 in response to the Georgetown report.

A separate report issued Dec. 3 by the American Lung Assn. found similar variations in smoking-cessation coverage among Medicaid plans. The ACA requires these programs to pay for tobacco cessation for pregnant women. Deciding who else to provide cessation coverage to is left to the states, although Medicaid frequently covers many recommended preventive services.

The report found that Indiana and Massachusetts covered comprehensive smoking cessation. Alabama and Georgia did not provide payment for such services.

The remaining states varied widely in the types of cessation services they covered. Researchers are concerned that such differences create confusion among patients and physicians.

“It's much easier for physicians to know what to do if everyone has the same coverage for this,” said Jennifer Singleterry, author of the lung association report and the organization's manager of national health policy.

Medicare offers more uniformity and covers two quit attempts per year. Each attempt may involve a maximum of four intermediate or intensive counseling sessions.

One in five Americans uses tobacco. The American Medical Association supports adequate funding of tobacco prevention and treatment programs.

“Every single smoker in America, regardless of their state of residence or economic status, should have access to the help they need to quit,” said AMA President Jeremy A. Lazarus, MD.