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It’s Covered: Financing for Tobacco Cessation Services

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Nina Marshall

Assistant Vice President, Healthcare Finance, National Council for Behavioral Health

It’s Covered: Financing for Tobacco Cessation Services

June 26, 2014 | Tobacco and Smoking | Comments
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Last week, Shelina Foderingham called on you to become a National Behavioral Health Network participant and start addressing the fact that half of tobacco-related deaths in the United States are among people with a behavioral health disorder. As with most all new services, however, the hard part isn’t convincing healthcare providers that the service has merit, it is figuring out the how – how to add onto everything else you already do, how to deliver it, and how to pay for it.

Luckily, the increased attention on preventive services under the Affordable Care Act has made tobacco cessation counseling and pharmacotherapy among the more clear-cut insurance benefits, at least at the federal policy level: they are required for all Essential Health Benefit-covered plans including Medicaid expansion plans, small group and individual health plans, and all Marketplace/Exchange plans. (On a related note, in January 2015 so will lung cancer screening for older adults with a history of smoking.) They are also required benefits under traditional Medicaid coverage for pregnant women and, as of January 1 of this year, Medicaid plans may no longer exclude tobacco-cessation medications even for traditional Medicaid recipients. Medicare’s benefit for counseling is limited but straightforward (up to eight sessions per year), and Medicare Part D plans must cover prescription medications (and may choose to cover over-the-counter drugs).

Great, you might say, but how does this translate on the ground? Here are some questions to ask the payors you work with:

  • Is there any guidance for required elements of the counseling? The US Preventive Services Task Force specifically names the “5-A’s” behavioral counseling framework in their recommendations.
  • Which practitioners are allowed to provide counseling services under your plan? The 5-A’s framework does not require licensed clinicians to deliver the counseling.
  • Are there limits on the number of counseling sessions per year? Tobacco use is a chronic, relapsing condition and it often can take multiple quit attempts to be successful.

For some help on coding the services, the American Academy of Pediatrics has put together a great collection of resources on coding and payment for tobacco cessation services.

To help you figure out the other hows – like incorporating it into your existing services and training staff – check out the American Lung Association’s resources and (again) join the National Behavioral Health Network. I invite you to join the conversation as we learn how to apply the lessons already learned for the general population and develop best practices for people with behavioral health disorders.

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