Tobacco Cessation Treatment: What Is Covered? | American Lung Association

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Tobacco Cessation Treatment: What Is Covered?

The Affordable Care Act (ACA) and other federal laws and rules require almost all health insurance plans in the U.S. to cover some level of tobacco cessation treatments. The following chart gives details of these requirements. Note that information on this chart does not guarantee coverage for certain treatments in any insurance plan – policymakers and regulators must enforce these requirements and insurance plans and employers must implement them. Patients should check with their plan to confirm which treatments are covered.

Insurance Type: Medicare  

Who's Covered?

Age 65+ or some disabled individuals

Required Coverage

  • Cessation medications: nicotine nasal spray, nicotine inhaler, bupropion and varenicline. Part D plans may opt to cover other medications.
  • 4 sessions of individual counseling
  • Up to 2 quit attempts per year
  • No cost-sharing for patients not showing symptoms of a tobacco-caused disease
  • Annual prevention visit

Insurance Type: Traditional Medicaid

Who's Covered?

Low-income or disabled individuals, eligibility varies by state

Required Coverage

For pregnant women:

  • Individual, group and phone counseling
  • All FDA-approved smoking cessation medications

For all Medicaid enrollees:

  • All FDA-approved smoking cessation medications

Insurance Type: Medicaid Expansion

Who's Covered?

Low-income or disabled individuals, up to 138 percent of federal poverty level in states that expand Medicaid

Required Coverage

  • Tobacco cessation as a preventive service. Federal guidance defines this as:
    • 4 sessions of individual, group and phone counseling
    • 90 days of all FDA-approved smoking cessation medications
    • 2 quit attempts per year
    • No prior authorization for treatments

Insurance Type: State Health Insurance Marketplace Plans

Who's Covered?

Individuals who buy plans through healthcare.gov or their state’s marketplace. Subsidies for these plans are available to those earning 100-400 percent of the federal poverty level.

Required Coverage

  • Tobacco cessation as a preventive service. Federal guidance defines this as:
    • 4 sessions of individual, group and phone counseling
    • 90 days of all FDA-approved smoking cessation medications
    • 2 quit attempts per year
    • No prior authorization for treatments
  • No cost-sharing

Insurance Type: Employer-Sponsored Insurance

Who's Covered?

Individuals who receive health insurance through their employer, association, union or other organization.

Required Coverage

  • Tobacco cessation as a preventive service. Federal guidance defines this as:
    • 4 sessions of individual, group and phone counseling
    • 90 days of all FDA-approved smoking cessation medications
    • 2 quit attempts per year
    • No prior authorization for treatments
  • No cost-sharing

Insurance Type: Grandfathered Health Plans

Who's Covered?

Individuals enrolled in a plan that was in existence before March 2010 and has not made significant changes since

Required Coverage

No requirements, but plans may opt to cover tobacco cessation treatment

Cost-sharing: money a patient must pay when receiving treatment/filling a prescription: copays, coinsurance, deductibles, etc.
Federal Poverty Level: a measure of income level issued annually by the federal government. These levels are used to establish eligibility for certain programs and benefits, including Medicaid and eligibility for subsidies for health insurance. For more information, visit https://www.healthcare.gov/glossary/federal-poverty-level-FPL/


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