In 2014, 32 percent of Medicaid enrollees were smokers, compared with 17 percent of the general population. Tobacco use is the leading cause of preventable death in the U.S., with more than 480,000 deaths each year caused by cigarette smoking.
Tobacco Cessation Insurance Coverage
Why is Insurance Coverage of Tobacco Cessation Important?
Tobacco use is the leading cause of preventable death in the U.S., with more than 480,000 deaths each year caused by cigarette smoking.1,2 This includes 32 percent of all cancer deaths and 80 percent of lung cancer deaths.3 Approximately one fourth of American adults use some form of tobacco, including 32 percent of Medicaid enrollees.4,5 However, more than two-thirds of smokers report that they want to quit completely and more than 50 percent have attempted to quit in the past year.6 Tobacco dependence treatment is considered the gold standard of health cost effectiveness because the benefits outweigh the costs. Evidence shows that tobacco cessation benefits help people quit smoking and that quit rates are higher when health insurance covers this benefit.7 People are more able to utilize tobacco cessation services when they do not have to pay for expensive treatment out of pocket.
Comprehensive Cessation Benefits Should Include Coverage for:
What Does a Comprehensive Tobacco Cessation Benefit Include?
All insurance plans, regardless of payer, should provide a comprehensive tobacco cessation benefit. The United States Preventive Services Task Force (USPSTF) recommends, with an A rating, that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved medications to adults who use tobacco (except for pregnant women). The U.S. Public Health Service Guide to Treating Tobacco Use and Dependence and the USPSTF recommend providing both counseling and medications to people who use tobacco.8,9 While each type of treatment is effective on its own, a combination of medication and behavioral counseling is most effective.
A comprehensive tobacco cessation benefit includes coverage for three different types of counseling (individual, group, and phone, including the state’s Quitline) and seven FDA-approved pharmacological interventions (five nicotine replacement therapies and two additional prescription medications) without barriers to access. Tobacco users should be offered at least four counseling sessions and a 90-day supply of medication for each quit attempt and at least two quit attempts should be covered per year. People respond differently to different interventions; therefore, coverage for a range of counseling types and medications is essential.
Barriers to Tobacco Cessation Services
In addition to ensuring access to a comprehensive tobacco cessation benefit, it is important for enrollees to be able to access these services without barriers. There are six key barriers that prevent enrollees from utilizing comprehensive cessation programs: co-payments, prior authorization requirements, limits on treatment duration, yearly or lifetime dollar limits, step therapy, and required counseling for medications. Research shows that enrollees are more likely to quit successfully if their coverage does not impose barriers to care.10
Co-payments are fixed charges paid by the enrollee at the time of service. Federal law prohibits marketplace plans and Medicaid expansion plans from charging co-pays for tobacco cessation treatment, but some traditional Medicaid plans still include co-pays for cessation services. Evidence shows that co-pays reduce the use of cessation medications and reduces the overall success of quitting; therefore, states should not impose co-pays for tobacco cessation interventions in any insurance plans.11,12
A Comprehensive Cessation Benefit Poses No Barriers to Accessing Services:
Prior Authorization Requirements
Prior authorization requires the physician or the patient to contact their insurance provider first before receiving a prescription. This can lead to delays in treatment and cause an extra workload for the physician, particularly those providing care for a high volume of patients. It also causes significant stress for the patient if they have the burden of contacting the insurance company themselves, and may prompt them to abandon their treatment.
Limits on Treatment Duration
According to the American Cancer Society, it may take up to 10 attempts to successfully quit smoking.13 Limiting the number of counseling visits or medication refills that insurance companies cover will only harm and punish patients who are trying to quit and may need additional counseling sessions or medication to be successful. According to data cited by the USPSTF, brief in-person counseling sessions effectively increases the proportion of adults who remain abstinent from smoking for one year.14 ACS CAN advocates that insurers fully cover at least four counseling sessions and at least a 90-day supply of medication per quit attempt.
Yearly or Lifetime Dollar Limits
Limiting the dollar coverage allowed for tobacco cessation is also a barrier to helping tobacco users quit. The cost of treatment depends on a variety of factors, including what type of medication and/or counseling a patient is using and the length of their treatment. Limits on the dollar amount plans will spend on an individual enrollee prevents the enrollee from receiving the full course of treatment based on their individuals needs for quitting sucessfully. Tobacco is incredibly addictive, and it may take many attempts to achieve the right treatment regimen that helps the patient successfully quit. Very few people achieve long-term success with an initial quit attempt.15 ACS CAN advocates that insurers fully cover a comprehensive tobacco cessation benefit for a minimum of two cessation attempts per year.
Step therapy involves enrollees being required to try and fail on less expensive treatments before more expensive medications will be covered. This could force enrollees into a cycle of trying out treatments they have already deemed ineffective if they have to restart at the bottom of the ladder each time. The imposition of step therapy on tobacco cessation medications ignores the fact that some treatment modalities (patch, medications, etc.) are more effective for some enrollees than others. Personalized recommendations for the most effective treatment should be made for each individual, even if that means starting the person on a more expensive medication.
Requiring Counseling for Medications
While the best practice to help people stop tobacco use is a combination of counseling and medication, plans should not require patients to receive counseling before obtaining cessation medications. This could deter patients from even attempting to quit because they may be opposed to the idea of counseling, or lack the time to attend counseling. In these situations, the person’s preferences should be prioritized and counseling requirements should not present a barrier to accessing FDA-approved cessation medications.
Status of Insurance Coverage and Coverage Gaps
While federal law requires many plans to cover tobacco cessation services, detailed below, there is significant variation based on type of insurance and specific plan in coverage of tobacco cessation benefits. Even where coverage requirements exist, they are often vague or confusing for enrollees to understand, and may not be fully implemented consistent with current law. Actions should be taken to clarify coverage requirements across plans, so that enrollees can understand what is covered and have access to all forms of cessation support.17
Under current law, non-grandfathered marketplace plans are required to cover preventive services that have an A or B rating from the USPSTF, including tobacco cessation treatments, without cost-sharing. However, current law does not specify what constitutes tobacco cessation benefits. As a result, not all plans cover all cessation treatments, and some plans are vague, or even contradictory about what is covered and any cost-sharing. Some private insurance plans require patients to prove “medical necessity” for the cessation treatments.18 This could be due to the fact that the plan documents have not been properly updated to comply with current law or because the USPSTF guidelines are not written as a coverage benefit since they are intended to be used by clinicians. Specific coverage requirements for marketplace plans vary from state to state, further contributing to disparities in coverage.19,20
Medicaid Expansion Plans
Like marketplace plans, Medicaid expansion plans must also cover preventive services with an A or B rating from the USPSTF, including tobacco cessation treatments, without cost sharing. This leads to some of the same coverage gaps previously discussed.21 As of 2016, only nine of 32 states that expanded Medicaid covered all cessation treatments, and 19 states covered all seven FDA-approved cessation medications.22
Traditional Medicaid Plans
All Medicaid plans are required to cover tobacco cessation benefits for pregnant women and are incentivized to cover them for all enrollees through a one percent increase in their federal matching rate if the state covers all preventive services. As a result, Medicaid cessation coverage varies by state. States can choose what services they want to cover, and may set requirements or limits for treatment. There are also no restrictions against cost sharing. This can be detrimental to enrollees trying to access cessation benefits, because Medicaid enrollees have higher rates of smoking than the general population and are by definition lower income, so they need this benefit the most but are unable to afford it. Ten states do not offer any type of counseling or medication coverage for their enrollees.23 See our fact sheet for more information about the status of traditional Medicaid coverage.24
Current law prohibits Medicare from charging cost-sharing for tobacco cessation benefits as this is considered a preventive service. Medicare covers up to eight face-to-face smoking cessation counseling visits in a 12-month period when provided by an approved practitioner that accepts Medicare. Coverage of cessation medications in Medicare varies by plan.25
ACS CAN’s Recommendations
ACS CAN recommends that all public and private health care coverage include a comprehensive tobacco cessation benefit with access to all three types of counseling and all FDA-approved medications, without cost-sharing to the patient or other barriers, for all enrollees. While federal law has been effective in increasing coverage of tobacco cessation services for pregnant women on Medicaid and enrollees in most private insurance and Medicaid expansion plans, there are still gaps in coverage, particularly when it comes to enrollees in traditional Medicaid plans. Requiring all plans to provide a comprehensive tobacco cessation benefit and without barriers is key to helping people quit tobacco use. Ultimately this public health intervention will save lives.
1. Office of the Surgeon General. The health consequences of smoking—50 years of progress: a report of the surgeon general [Internet]. Rockville (MD): The Office; 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/fullr...
2. Ku L, Bruen BK, Steinmetz E, Bysshe T. Medicaid Tobacco Cessation: Big Gaps Remain In Efforts To Get Smokers To Quit. Health Affairs. 2016;35(1):62-70. doi:10.1377/hlthaff.2015.0756.
3. American Cancer Society. Cancer Facts & Figures 2017. Atlanta: American Cancer Society, 2017.
4. King, B. A., Dube, S. R., & Tynan, M. A. (2012). Current Tobacco Use Among Adults in the United States: Findings From the National Adult Tobacco Survey. American Journal of Public Health,102(11). doi:10.2105/ajph.2012.301002
5. Office of the Surgeon General, 2014.
6. Asman K, O'Halloran A. Quitting Smoking Among Adults --- United States, 2001--2010. Centers for Disease Control and Prevention; MMWR 2011. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6044a2.htm. Accessed July 25, 2017.
7. Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recomm...
8. Final Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. United States Preventative Services Task Force; 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendati.... Accessed July 14, 2017.
9. Treating Tobacco Use and Dependence, 2013.
10. McMenamin SB, Halpin HA, Bellows NM. Knowledge of Medicaid coverage and effectiveness of smoking treatments. Am J Prev Med. 2006; 31(5):369–74.
11. Curry SJ, Gorthaus LC, McAfee T, Pabiniak P. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med. Sep 3 1998; 339(10):673-9.
12. Hughes JR, Wadland WC, Fenwick JW, Lewis J, Bickel WK. Effect of cost on the self-administration and efficacy of nicotine gum: A preliminary study. Prev Med. July 1991; 20(4):486–96.
13. American Cancer Society. Guide to Quitting Smoking. http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking... (accessed 26 Jul 2013).
14. Final Recommendation Statement: Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. United States Preventative Services Task Force; 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/Recommendati.... Accessed July 14, 2017.
15. Survey of State Quitline Efforts to Build Relationships and Cost-Sharing Strategies with State Medicaid Agencies: Current Landscapes and Critical Questions for the Work Ahead. North American Quitline Consortium; 2015. http://c.ymcdn.com/sites/www.naquitline.org/resource/resmgr/medicaid/Med.... Accessed July 13, 2017.
16. Kofman M, Dunton K, Senkewicz MB. Implementation of tobacco cessation coverage under the Affordable Care Act: Understanding how private health insurance policies cover tobacco cessation treatments.; 2012. https://www.tobaccofreekids.org/pressoffice/2012/georgetown/coveragerepo...
18. Centers for Disease Control and Prevention: Coverage for Tobacco Use Cessation Treatments. January 2014. https://www.cdc.gov/tobacco/quit_smoking/cessation/pdfs/coverage.pdf
20. Kofman M, Dunton K, Senkewicz MB. Implementation of tobacco cessation coverage under the Affordable Care Act: Understanding how private health insurance policies cover tobacco cessation treatments.; 2012.
21. Centers for Disease Control and Prevention: Coverage for Tobacco Use Cessation Treatments. January 2014.
22. DiGuilio, A., Haddiz, M., Jump, Z., Babb, S., Schecter, A., Williams, K. S., . . . Armour, B. S. (2016, December 9). State Medicaid Expansion Tobacco Cessation Coverage and Number of Adult Smokers Enrolled in Expansion Coverage - United States, 2016. MMWR (Rep. No. 48). Retrieved June 27, 2017, from Centers for Disease Control and Prevention website.
24. Kofman, 2012.
25. Kries D. Smoking Cessation & Medicare Coverage. Medicare Information, Help, and Plan Enrollment - Medicare.com. https://medicare.com/coverage/does-medicare-cover-smoking-cessation-trea.... Published December 5, 2016. Accessed July 25, 2017.