What must group health plans provide as preventive coverage for tobacco cessation interventions?


The Patient Protection and Affordable Care Act (ACA) contains preventive coverage provisions that require non-grandfathered group health plans and health insurance coverage offered in the group market to provide benefits for evidenced-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force (USPSTF). The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. What are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions?


Plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance for plans and issuers.

The Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions if, for example, the plan or issuer covers without cost-sharing:

    1. Screening for tobacco use; and

    2. For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for:

      • Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and

      • All FDA-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

Source: FAQs about Affordable Care Act Implementation (Part XIX), Q5, May 2, 2014; http://www.dol.gov/ebsa/pdf/faq-aca19.pdf.

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