Health Plans Fail To Comply With The ACA In Tobacco Cessation Coverage

Many health insurance plans don’t provide the tobacco cessation coverage that’s mandated by the health care reform law, according to a study of insurance contracts. 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 Inc.

Researchers found many policies rife with confusing and conflicting language that could discourage consumers from seeking treatment. Many policies also have gaps in coverage for cessation counseling and medication as well as cost-sharing requirements that appear to conflict with the law.

Under the ACA, all new private health insurance plans must cover preventive health services recommended with an A or B grade by the U.S. Preventive Services Task Force (USPSTF). The coverage must be provided without cost sharing, such as co-pays.

The following are key findings of the study:

• Thirty-six contracts said that they cover tobacco cessation or that they are providing coverage that’s consistent with the USPSTF recommendations, but 26 of these contracts include language that entirely or partially excludes tobacco cessation from coverage. For example, one contract states that preventive adult wellness services are covered. But, in another section, the contract includes smoking cessation on a list programs that are not covered.

• Only four of the 39 plans stated they covered individual, group and phone counseling and prescription and over-the-counter (OTC) medications.

• Many policies excluded certain types of counseling and provided no coverage of prescription and OTC medications for tobacco cessation.

• In 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.

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids said, “It 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.”

The report makes the following recommendations to federal and state regulators:

• Regulators should require health insurance policies to include a clear statement that tobacco cessation treatment is a covered benefit. Policies should state which treatments are covered and state that cost sharing does not apply.

• Regulators should provide guidance on permissible and prohibited limitations to coverage under the ACA.

• Federal regulators should provide model contract language for this benefit to help address ambiguities over what benefits are available to consumers and how to access them.

Guidance issued by the U.S. Office of Personnel Management (OPM) for the Federal Employees Health Benefit Program is an excellent model to help define the scope of coverage required by the ACA, say researchers. OPM instructs 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. For more information, visit http://tfk.org/coveragereport.

Last Updated 9/8/2017

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