Insurance coverage for tobacco cessation varies widely and is often explained in convoluted and occasionally contradictory contract language, a study of 39 health plans has found.
Researchers at the Georgetown University Health Policy Institute recently studied the state of tobacco cessation coverage after the Affordable Care Act mandated it and other coverage recommended by the U.S. Preventive Services Task Force.
They reviewed 39 insurance contracts from policies sold in Florida, Kentucky, Nevada, New Jersey, Oregon and South Dakota, including 12 individual plans, 18 small group plans, six state employee benefit plans and three federal employee benefit plans.
The researchers found wide variation, with some contracts appearing to exclude tobacco cessation coverage and others having conflicting benefit descriptions.
While 36 of the contracts provide smoking cessation coverage, 26 of them "also included language excluding tobacco cessation from coverage entirely or partially."
Reading the contracts left Georgetown health research professor Mila Kofman scratching her head. "It's not only murky, it's also contradictory and almost impossible to figure out," said Kofman, previously Maine's insurance superintendent from 2008 to 2011.
One contracts says the plan covers evidence-based services with A and B ratings in the U.S. Preventive Services Task Force's current recommendations -- and then later lists smoking cessation programs under "what is not covered." Another contract says cessation therapies are covered, and later says, "Except as specifically provided in this Policy, We do not cover treatment of tobacco addiction and supportive items."
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That type of conflicting language, Kofman said, may stem from companies failing to delete pre-ACA exclusions from their contracts. Or it "could mean that the issuer is intentionally not complying with the ACA."
Either way, Kofman said, the contracts' contradictions may leave some smokers unsure if their plan actually covers cessation treatment.
Tobacco use is considered a chronic condition, and is the leading cause of preventable death in the U.S., leading to some 400,000 annual deaths and costing the nation $193 billion annually in medical costs and lost productivity, according to the Georgetown study. Surveys show about 70 percent of current smokers want to quit, Kofman said, and the U.S. Public Health Service's tobacco task force maintains that more smokers participate in cessation programs -- including medication and counseling -- when it is covered by a health plan.
For individual counseling, the study found that 17 health plans covered it, four excluded it and 16 mentioned the U.S. Preventative Services Task Force's recommendations but didn't specify coverage.
The study found that coverage for over the counter medication, such as Nicorette Gum, varied widely, with 12 covering over the counter cessation products and 24 excluding them. Twenty-three of the 29 contracts covered prescription drugs like Zyban and Chantix, which blocks nicotine from attaching to brain receptors.
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Another issue the researchers examined is cost-sharing. The ACA requires all new private health plans to cover services recommended by the U.S. Preventive Services Task Force with no cost-sharing. The study found that seven contracts covering counseling and six of the contracts covering prescription drugs required co-pays.
Health plans may be increasingly aligning themselves with the ACA, Kofman said, and as guaranteed issue and individual mandate provisions take effect, there may be more incentives to offer no-cost cessation programs. Until now, Kofman added, the high turnover in the individual insurance market has left health plans without a good long-term reason to cover cessation and other prevention and wellness benefits at no-cost.
The Georgetown researchers, along with the Campaign for Tobacco-Free Kids, which partly funded the study, are urging state regulators to require health plans to clearly list tobacco cessation treatment as a covered benefit without cost-sharing. They're also recommending that federal regulators should draft model language for the benefit.
The study pointed to the Federal Employees Health Benefits Program as a model for defining the scope of cessation coverage required by the ACA. With guidance from the U.S. Office of Personnel Management, federal employee insurance plans have to cover at least two attempts to quit smoking per year, with up to four counseling session as well over the counter and prescription medications.