08/24/2011
Benefit clarification: Tobacco cessation
Some of the Patient Protection and Affordable Health Care Act's mandated first-dollar preventive services resulted from recommendations made by the United States Preventive Services Task Force (USPSTF).
We've completed a close review of the USPSTF recommendations concerning tobacco-cessation services and have concluded that tobacco counseling and generic prescription medications for tobacco cessation should be included in first-dollar preventive benefits.
The USPSTF recommendations don't specifically identify which prescriptions should be covered. Therefore, we're limiting first-dollar tobacco-cessation coverage to generic medications only; over-the-counter medications won't be covered.
In addition, if a group is subject to the Mental Health Parity and Addiction Equity Act (MHPAEA) and provides benefits for treatment of substance abuse (such as tobacco cessation), the benefit must be provided at parity with the medical benefits in all classifications (inpatient in- and out-of-network, outpatient in- and out-of-network, emergency care, and prescription drugs).
While at this point the MHPAEA doesn't apply to Individual coverage or to employers with 50 or fewer employees, we would be required to pay for the first-dollar preventive tobacco-cessation benefits in these products pursuant to health care reform law (unless grandfathered).
After evaluating the two laws, we've altered our benefits in the following manner:
- Non-grandfathered group plans (regardless of size):
- We've added tobacco-cessation treatment to the preventive benefit at existing Category 1, 2 and 3 levels or at existing preventive care category levels. Tobacco counseling is already included in the preventive benefit.
- We've added generic tobacco-cessation medications to the preventive benefit when dispensed from participating pharmacies.
- For plans with a prescription drug benefit (either with Asuris or an outside vendor), we've added non-generic tobacco-cessation prescription medications from participating pharmacies and generic tobacco-cessation medication from non-participating pharmacies to the regular pharmacy benefits.
- Grandfathered group plans (100+):
- These plans aren't impacted by preventive mandates but are subject to the MHPAEA if the group has a Free and Clear® Quit For Life® (now known as AlereTM Wellbeing Quit For Life®) or a similar program or covers tobacco-cessation drugs or benefits. In those cases, we'll add a tobacco-cessation benefit with no dollar limit and add associated prescription medications if the group has pharmacy benefits through Asuris.
- If a grandfathered group doesn't have a Free and Clear Quit For Life (now known as Alere Wellbeing Quit For Life) or a similar program and doesn't cover tobacco-cessation benefits or prescriptions, the group isn't required to add the benefit.
- We've been working to identify groups that have a similar tobacco-cessation benefit outside Asuris and are adding benefits as appropriate.
- Non-grandfathered Individual plans:
- We've added tobacco-cessation treatment to the preventive benefit at existing Category 1, 2 and 3 levels or at existing preventive care category levels. Tobacco counseling is already included in the preventive benefit.
- In addition, we've added generic tobacco cessation medications to the preventive benefit when dispensed from participating pharmacies. There is no coverage for non-generic prescription tobacco-cessation medications under the pharmacy benefit.
Administration
We've taken the following steps to implement tobacco-cessation benefits:
- Benefits for tobacco cessation became effective for contracts renewing on or after Oct. 1, 2010.
- If a member has already purchased a tobacco-cessation prescription drug, they may submit the claim to us for reimbursement.
- Our contract language has been reviewed and is consistent with the described tobacco cessation benefit.
- We strongly encourage all self-funded groups to adopt our approach; however, their plans bear the ultimate liability if they fail to comply with the MHPAEA. If they don't choose our approach, these plans will need to send written confirmation (an email will suffice) to their Asuris sales executive indicating that they've been notified of our interpretation but have chosen not to implement the recommended changes.
If you have questions, please talk to your Asuris sales contact.
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