Safe Harbor for Smoking Cessation Programs
Who: All group health plan or health insurance issuer plans covered by the Patient Protection & Affordable Care (PPACA) preventive care mandate.
When: On May 2, 2014, the Department of Labor’s Employee Benefits Security Administration issued a clarification of the PPACA preventive care coverage of smoking cessation programs and offered a safe harbor for compliance.
What: Smoking Cessation is mandated by PPACA to be covered at 100% without patient cost sharing. The law allows plans to use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service.
Safe Harbor: Plans are considered to be in compliance if the plan or issuer covers:
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:
a. Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and
b. All Food and Drug Administration (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.
Executive Summary: The Safe Harbor was offered in the context of the USPSFT smoking cessation Recommendation “A” that includes:
Screening: All adults (age 18 or older) should be screened for tobacco use at every provider visit. Adults who screen positive for tobacco use should be advised to quit and offered counseling and medication.
Counseling: At least two courses of 4 to 6 counseling sessions of at least 30 minutes each should be provided annually, for a total of 12 sessions per calendar year until the patient successfully quits smoking.
Counseling for tobacco use with pregnant women: The USPSTF strongly recommends that clinicians screen all pregnant women for tobacco use and provide augmented pregnancy-tailored counseling to those who smoke.
Treatment: Guidelines for the duration of medication treatment are specified in the Public Health Service Guideline and differ depending on the medication type. Patients identified as recently quit should be eligible for up to 4 additional counseling sessions and/or 4 to 8 weeks of medication to maintain tobacco abstinence (depending on the medication).
Actions: Employers and plan sponsors should consult with their agent, broker, plan consultant, legal counsel, or Human Resources Department to determine if existing smoking cessation programs meet the USPSTF requirements (or fall into the Safe Harbor). If any contract or administrative changes are needed, plan participants should be inform of the changes. Insurers will need to review their plan coverages and procedures to assure compliance.
The information presented and contained within this article was submitted by Ronald E. Bachman, President & CEO of Healthcare Visions and Chairman of the IHC Editorial Advisory Board. This information is general information only, and does not, and is not intended to constitute legal advice. You should consult legal advisors to determine the laws and regulations in your state. Any opinions expressed within this document are solely the opinion of the individual author.