Does Your Client Use Tobacco? | American Lung Association

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Does Your Client Use Tobacco?

Most states allow health plans sold through state marketplaces to charge tobacco users more in premiums than non-tobacco users—sometimes known as a tobacco surcharge. Federal subsidies do not take into account these surcharges.  Because of this, you probably already ask your clients if they use tobacco.

For clients who use tobacco, as you discuss plan options, make sure to note the higher premiums being charged because of tobacco use where applicable. Some plans allow tobacco users to avoid the surcharge by enrolling in a cessation (quit-tobacco) program.

Is Your Tobacco-Using Client Interested in Quitting?

While discussing these possible extra charges, and while discussing the client's general health, it is a great time to ask if he or she is interested in trying to quit. This is your opportunity to encourage your client to make an important change for their health, provide them with resources, and help them choose an insurance plan that covers the treatments they need to help them quit.

What Do Health Insurance Plans Cover for Quitting Tobacco?

Whether you are helping your client enroll in Medicaid or a marketplace plan, any plan option should cover treatments for tobacco cessation. Some level of tobacco cessation coverage is required in all of these plans by the Affordable Care Act. Below is information about the coverage required for each type of plan by federal laws and regulations:

Medicaid

Nicotine Patch

Coverage is required

Nicotine Gum

Coverage is required

Nicotine Lozenge

Coverage is required

Nicotine Nasal Spray

Coverage is required

Nicotine Inhaler

Coverage is required

Bupropion

Coverage is required

Varenicline

Coverage is required

Individual Counseling

Coverage is not required, but plan still may cover it

Group Counseling

Coverage is not required, but plan still may cover it

Phone Counseling

Coverage is not required, but plan still may cover it

Cost-sharing

Policies about copays vary by state

Prior authorization

Policies about prior authorization vary by state

As of January 1, 2014, Medicaid programs are no longer able to exclude any tobacco cessation medication from coverage (see Section 2502 of the Affordable Care Act). It is important to check the plan’s information to confirm which tobacco cessation treatments are covered. If you encounter a Medicaid plan that is not covering a tobacco cessation medication, note that information for the future and consider working with your state Department of Health or tobacco control groups to reach out to your state’s Medicaid program on behalf of your clients.

Marketplace Plans

Nicotine Patch

Coverage is required

Nicotine Gum

Coverage is required

Nicotine Lozenge

Coverage is required

Nicotine Nasal Spray

Coverage is required

Nicotine Inhaler

Coverage is required

Bupropion

Coverage is required

Varenicline

Coverage is required

Individual Counseling

Coverage is required

Group Counseling

Coverage is required

Phone Counseling

Coverage is required

Cost-sharing

Cost-sharing (copays, prior authorization, deductibles) is not allowed

Prior authorization

Prior authorization is not allowed

As of January 1, 2014, all plans offered through state marketplaces are required to cover the Essential Health Benefit which includes all preventive services given an 'A' or 'B' rating by the US Preventive Services Task Force (see Section 1302 of the Affordable Care Act). Tobacco cessation is given an 'A' rating, and details of what plans should cover for tobacco cessation are contained in Affordable Care Act Implementation FAQ XIX, Question 5.

The information above reflects these requirements, but some plans may interpret the requirements differently. It is important to check the plan’s information to confirm which tobacco cessation treatments are covered. If you encounter a plan that does not cover tobacco cessation treatments according to these requirements, note that for the future and also consider informing your state insurance regulator. You can also work with your State Department of Health or tobacco control group to encourage these plans to cover all cessation treatments on behalf of your clients.


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