OAFP Asks ODI to Enforce ACA Tobacco Cessation Benefit Requirements

On February 12, the Ohio Academy of Family Physicians joined other health advocates in sending a letter to Lieutenant Governor Mary Taylor, who is also the director of the Ohio Department of Insurance (ODI), asking that she ensure that health insurance plans are providing tobacco cessation benefits without cost sharing in accordance with requirements of the Affordable Care Act (ACA).

The letter reads as follows:
The ACA expands requirements for coverage of clinical preventive services in private health insurance plans. We are writing to urge you to take the steps necessary to ensure that health insurance plans under your authority are providing tobacco cessation benefits without cost sharing.

Our organizations look forward to working with you to ensure tobacco users in Ohio have the best possible chances to quit.

Prior to the ACA, federal law did not require group health plans and health insurance issuers to cover preventive services. Within six months of enactment of the ACA (September 23, 2010), group health plans and health insurance issuers in the group and individual markets were required to cover specified evidence?based clinical preventive services without any cost sharing. This includes coverage of preventive care under four broad categories: evidence?based screenings and counseling, routine immunization, childhood preventive services, and preventive services for women. Health plans in existence when the ACA was enacted are “grandfathered” under the law and are exempt from this requirement. As of January 1, 2014, more plans are now required to cover these preventive services: plans sold in state health insurance marketplaces/exchanges, and Alternative Benefit Plans serving the Medicaid expansion population.

The ACA requires plans to cover any evidence?based items or services that have an ‘A’ or ‘B’ rating in the current recommendations of the United State Preventive Services Task Force (USPSTF). With respect to tobacco cessation, the USPSTF recommends with an ‘A’ rating that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF recommendation also indicates that, “combination therapy with counseling and medications is more effective than either (counseling or pharmacotherapy) alone.”

The USPSTF recommendations were written as guidelines for clinicians, not as policy coverage language, resulting in ambiguity on what tobacco cessation coverage would look like in practice. And despite many insurance plans having been required to cover tobacco cessation as a preventive service since 2010, a 2012 study by Georgetown University’s Health Policy Institute found that only four of a cross section of 39 plans in six states analyzed in the study offered something approaching a comprehensive, evidence?based cessation benefit. Additionally, some of the 39 plans analyzed imposed cost?sharing requirements for tobacco cessation treatments, which is prohibited under the ACA for non?grandfathered plans.

As you may be aware, on May 2, 2014, the U.S. Departments of Health and Human Services, Labor, and Treasury issued further guidance, in the form of an FAQ, on insurance coverage of tobacco cessation as a preventive service. The guidance states that health plans that cover the following benefit, for example, would be considered to be in compliance:
  • Screening for tobacco use
  • Two quit attempts per year, consisting of:
    • Four sessions of telephone, individual, and group cessation counseling lasting at least 10 minutes each per quit attempt; and,
    • All medications approved by the Food and Drug Administration as safe and effective for smoking cessation (including both prescription and over?the?counter versions of medications), for 90 days per quit attempt, when prescribed by a health care provider.

The guidance also reiterates that plans must not include cost?sharing for these treatments, and that plans should not require prior authorization for any of these treatments.

Based on a review of websites of major plans in Ohio, we are aware that many plans are not following the guidance as the law requires, leaving many Ohioans who need help quitting without the services they need and are required to have under law.

As the head of ODI, you are in a unique position to assure Ohio’s tobacco users have access to this evidence?based cessation benefit. Our organizations ask you to issue a bulletin to insurance plans under your authority about this requirement and provide them information about the new guidance. Commissioners in other states have already issued such bulletins; we would be happy to share them with you.

We also encourage you to strictly enforce the requirement, including all the treatments listed in a comprehensive tobacco cessation benefit, and notify plans of your intent to do this in order to ensure the maximum number of tobacco users get the help they need to quit. Finally, it is critical to make sure that all plans provide coverage for tobacco cessation treatments as described above in all base health insurance products. If covered via rider, that rider should not be optional for purchasers.

While progress has been made to reduce tobacco use, it remains the leading cause of preventable death and disease in the United States. Smoking is responsible for one in three cancer deaths, eight in 20 cases of Chronic Obstructive Pulmonary Disease (COPD), and one in three heart disease deaths, and results in medical costs of at least $130 billion a year. Ohio has the 11th worst smoking rate in the country.

Smoking costs our state $5.64 billion in health care costs every year. $1.4 billion of that is the portion covered by the state Medicaid program for smoking?caused costs.

Our organizations welcome the opportunity to meet with you to talk more about these requirements, answer questions, and tell you more about other efforts in Ohio designed to encourage and assist tobacco users in quitting.

Our organizations look forward to working with you to make sure all tobacco users in Ohio have the resources they need to quit successfully.

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Disclaimer: The views and opinions expressed in comments published in Weekly Family Medicine Update (WFMU) are those of the writers alone. They do not represent the views or opinions of Ohio Academy of Family Physicians (OAFP) or its staff. Comments are automatically posted live; however, OAFP reserves the right to take down comments at any time.

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