Georgetown University Researchers Find Confusing Language and Coverage Gaps in Contracts
WASHINGTON, Nov. 26, 2012 /PRNewswire-USNewswire/ -- Many health insurance plans are failing to provide coverage mandated by the health care reform law for treatments to help smokers and other tobacco users quit, according to a study of insurance contracts by Georgetown University researchers conducted for the Campaign for Tobacco-Free Kids. The authors recommend that federal and state regulators give insurers detailed guidance on what tobacco cessation coverage is required under the landmark Affordable Care Act (ACA).
The ACA requires all new private health insurance plans to cover preventive health services recommended with an A or B grade by the U.S. Preventive Services Task Force (USPSTF), with no cost-sharing such as co-pays. These recommendations include tobacco cessation treatments, which received an A grade. The USPSTF recommends that clinicians ask adults about tobacco use and provide cessation interventions for tobacco users. It found that more or longer counseling sessions improve quit rates and combining counseling with medication is more effective for treating tobacco dependence than either therapy used alone.
To determine how the cessation coverage requirement is being implemented, insurance experts at the Georgetown University Health Policy Institute analyzed 39 health insurance plans sold in six states, including individual, small group, federal employee and state employee plans. The study was commissioned by the Campaign for Tobacco-Free Kids with funding from Pfizer, Inc.
The researchers found that many policies are rife with confusing and conflicting language that could leave consumers uncertain if tobacco cessation treatments are covered and discourage them from seeking these treatments. It also found that many policies included gaps in coverage for cessation counseling and medication and cost-sharing requirements that appear to conflict with the law.
Specific findings include:
- While 36 contracts indicated that they covered tobacco cessation or are providing coverage consistent with the USPSTF recommendations, 26 of these contracts also included language entirely or partially excluding tobacco cessation from coverage. For example, one contract states "preventive adult wellness Services are covered... that have in effect a rating of 'A' or 'B' in the current recommendations" of the USPSTF. The same contract, in the "what is not covered" section, lists "Smoking Cessation Programs including any Service to eliminate or reduce the dependency on, or addiction to, tobacco, including but not limited to nicotine withdrawal programs and nicotine products (e.g., gum, transdermal patches, etc.)."
- There was wide variation in coverage for cessation counseling and medication, raising concern that treatments found to be effective by the USPSTF and required under the ACA are not being covered. Only four of the 39 plans stated they covered individual, group and phone counseling and both prescription and over-the-counter (OTC) medications. Many policies specifically excluded certain types of counseling and provided no coverage of prescription and OTC medications for tobacco cessation.
- In apparent conflict with the law, some policies included cost-sharing requirements. Seven of 36 contracts that clearly covered counseling required cost-sharing for counseling by in-network providers, and six of 24 contracts that covered prescription drugs required cost-sharing.
"The Affordable Care Act recognized that coverage for preventive care, including helping people quit tobacco, is a critical part of improving health and reducing health care costs in our country," said Matthew L. Myers, President of the Campaign for Tobacco-Free Kids. "Tobacco use is a leading risk factor for cancer, heart and lung disease and other serious chronic conditions. Covering effective tobacco cessation treatments is a smart way for insurers to avoid the cost of future illness, and it is the law."
"It is shocking to see the huge variation in what appears to be a straight forward inexpensive benefit that has significant medical evidence on treatment that works," Mila Kofman, principal author of the report and former Maine Superintendent of Insurance said, "It is even more disappointing to find that some in the insurance industry are trying to avoid covering tobacco cessation treatment as required by the Affordable Care Act."
The report made the following recommendations to federal and state regulators:
- Regulators should require that health insurance policies include a clear statement that tobacco cessation treatment is a covered benefit. Policies should specifically state which treatments are covered and that cost-sharing does not apply.
- Regulators should provide guidance on permissible and prohibited limitations to coverage under the ACA.
- Federal regulators should provide model contract language for this benefit, which would help address ambiguities and uncertainties over what benefits are available to consumers and how to access such benefits.
- Guidance issued by the U.S. Office of Personnel Management (OPM) for the Federal Employees Health Benefits Program is an excellent model to help define the scope of coverage required by the ACA. OPM instructed insurers to cover tobacco cessation treatments without cost-sharing. Insurers must cover at least two quit attempts per year with up to four cessation counseling sessions of at least 30 minutes each (including individual, group and phone counseling). They must also cover OTC and prescription medications.
"Absent detailed guidance, huge variations in benefits will continue to be a problem, and tobacco users' access to tobacco treatment will continue to be limited. Finally, absent additional steps by federal or state regulators, the promise of reducing tobacco use – saving lives and saving health care resources – will not be realized fully," the report concludes.
Tobacco use is the leading cause of preventable death in the United States, killing more than 400,000 Americans and costing the nation $96 billion annually in direct medical costs.
The study can be found at http://tfk.org/coveragereport/.
SOURCE Campaign for Tobacco-Free Kids