A recent study from Georgetown University’s Health Policy Institute on tobacco cessation coverage subsequent to the Affordable Care Act (ACA) overlooked many issues related to implementation of the ACA preventive services provision.
Health plans have a long-standing commitment to evidence-based prevention and wellness programs and services, including tobacco cessation, for more than a decade. According to an AHIP survey of member health plans prior to the passage of the ACA, nearly all (97 percent) health plans were offering interventions for tobacco use, including screening and counseling services and coverage for prescription medications. Furthermore, for the last ten years, the majority of health plans (approximately 90 percent) have provided coverage for at least one type of pharmacotherapy for tobacco cessation, according to another AHIP survey.
Almost a decade ago, AHIP and its partners made the business case for evidence-based tobacco cessation programs with the development of its Return On Investment Calculator, which showed that plans and employers offering evidence-based tobacco interventions saw a ROI after approximately two years. For many years prior to the ACA, health plans partnered with employers, clinicians, community-based organizations, and public health experts to prevent tobacco use and improve the health of members and communities.
Today, health plans are following U.S. Preventive Services Task Force (USPSTF) recommendations as the ACA requires, and have eliminated cost sharing where specified by the ACA. The USPSTF outlined different interventions that are found to be effective in increasing tobacco cessation rates, including different counseling modalities, alone or in combination with various FDA-approved medications. With regard to tobacco cessation, the ACA preventive services provision (Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act [7/19/2010]) recognized that there is not a one-size-fits-all approach, and thus allows for flexibility about the “frequency, method, treatment, and settings for recommended preventive services.” Therefore, we would expect to see variation in approaches among health plans around the benefit for tobacco cessation.
USPSTF recommendations are guidance for clinical practice, and there is likely a need for additional clarity as health plans apply these clinical recommendations to benefit design. There may be questions regarding when “prevention” (where no cost sharing is permitted) crosses over into “treatment” (where cost sharing is permitted), and also questions about coverage for such items as prescription and over-the-counter medications. In regulatory comments about these issues, AHIP has indicated that there is a need for further guidance.