Insurance Coverage for Tobacco Cessation

PACT Recommendation: Adopt legislative or regulatory standards for comprehensive smoking cessation treatment coverage by insurance companies and Medicaid programs in Pennsylvania. Adopt legislation to prohibit tobacco surcharges across all health insurance plans in Pennsylvania.

In 2010, over half of adult smokers in Pennsylvania made an attempt to quit.[i] However, some estimates suggest that the average smoker may make 20-30 quit attempts prior to successfully quitting. Because so many quit attempts are unsuccessful, it is crucial to ensure that smokers who are motivated to quit have access to the resources that will best enable them to do so.[ii]

Pennsylvania does not guarantee comprehensive insurance coverage for smoking cessation.[v] Currently, Medicaid programs in Pennsylvania cover all seven recommended cessation medications, as well as individual and group counseling. However, this coverage has several barriers, including limits on counseling duration, limits on counseling per year, and minimal copayments.[vi] Many commercial plans offer nominal benefits, such as a limited number of counseling sessions, or coverage for only one type of smoking cessation medication. Even the Pennsylvania Employees Benefit Trust fund, which provides health benefits to the state government’s 80,000 employees, denies access to comprehensive smoking cessation coverage.[vii]

Insurance companies and Medicaid contractors should cover comprehensive tobacco cessation treatments and eliminate barriers to their use, including required co-payments, prior authorization requirements, limits on treatment duration, yearly or lifetime limits, dollar limits, “stepped care” therapy, and counseling requirements for medication.[viii]

Increasing access to cessation treatments will help smokers in Pennsylvania quit, saving lives while reducing short and long-term costs. Economic analyses of cessation coverage substantiate the efficacy of such approaches: one review estimates that employer savings total more than $5.00 for every dollar spent covering cessation.[ix] Tobacco cessation is more cost-effective than other common and covered disease prevention interventions, such as the treatment of hypertension and mammography screenings,[x] and should be a standard insurance benefit for all Pennsylvanians.

A tobacco surcharge is a variation in insurance premiums based on a policyholder (or dependent’s) tobacco use. Tobacco surcharges are sometimes called tobacco premiums, premium incentives, or non-smoker discounts.

CDC Recommendations

The CDC recommends the use of smoking cessation treatments, including counseling, nicotine replacement products, and non-nicotine cessation medications; the use of counseling in combination with appropriate medication is significantly more effective than using either one alone.

Foot Notes

[i] Centers for Disease Control and Prevention (CDC). Smoking and Tobacco Use: State Highlights 2012: Pennsylvania. Available https://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2012/states/pennsylvania/index.htm[ii] Chaiton, Michael, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open 6.6 (2016): e011045.

[iii] Centers for Disease Prevention and Control (CDC). Smoking and Tobacco Use: Quitting Smoking. Available https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/

[iv] Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. 6, Evidence and Recommendations. Available https://www.ncbi.nlm.nih.gov/books/NBK63943/

[v] American Lung Association. Pennsylvania Tobacco Cessation Coverage. 2014. Available http://lungusa2.org/cessation2/statedetail.php?stateId=42

[vi] American Lung Association. State Tobacco Cessation Coverage Database: Pennsylvania. Available http://www.lungusa2.org/cessation2/statedetail.php?stateId=42

[vii] American Lung Association. State Tobacco Cessation Coverage Database: Pennsylvania. Available http://www.lungusa2.org/cessation2/statedetail.php?stateId=42

[viii] American Lung Association. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage—United States 2008-2014. Available http://www.lung.org/assets/documents/tobacco-control-advocacy/highlights-state-medicaid.pdf

[ix] Halpern, Michael T., et al. Economic model of sustained-release bupropion hydrochloride in health plan and work site smoking-cessation programs. American Journal of Health-System Pharmacy 57.15 (2000): 1421-1429.

[x] The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update: A U.S. Public Health Service Report. American Journal of Preventive Medicine. 2008;35(2):158-176. doi:10.1016/j.amepre.2008.04.009.

[xi] Friedman, Abigail S., William L. Schpero, and Susan H. Busch. Evidence Suggests That The ACA’s Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation. Health Affairs 35.7 (2016): 1176-1183.

[xii] American Lung Association. Tobacco Surcharges. Available http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/2013/factsheet-tobacco-surcharges-v2.pdf