In 2014, the Patient Protection and Affordable Care Act (ACA) began requiring isurance plans to cover many clinical preventive services(www.healthcare.gov). Two of the covered preventive services include:
Medicare Part B covers two levels of tobacco cessation counseling for symptomatic and asymptomatic patients: intermediate and intensive.
Two cessation attempts are covered per 12-month period. Each attempt may include a maximum of four intermediate or intensive counseling sessions. Therefore, the total annual benefit covers up to eight smoking cessation counseling sessions in a 12-month period.
The patient may receive another eight counseling sessions during a second or subsequent year once 11 full months have passed since the first Medicare-covered cessation counseling session took place.
For counseling to qualify for Medicare payment, the following criteria must be met at the time of service:
Symptomatic patients are those who use tobacco and:
Both cosinsurance and deductible apply.
Use the following codes for symptomatic patients.
Asymptomatic patients are those who use tobacco but do not have symptoms of tobacco-related disease.
Both coinsurance and deductible are waived.
Use the following CPT codes for asymptomatic patients.
Many states offer some payment for individual tobacco cessation and treatment counseling for Medicaid patients. For example, the ACA requires states to expand Medicaid coverage of cessation services for pregnant women. You are encouraged to contact your state Medicaid office for coverage information in your specific state.
The Centers for Medicare and Medicaid Services encourage state partners to support smoking cessation by ensuring coverage of all FDA-approved smoking cessation medication (prescription and over-the-counter [OTC]) without a copayment requirement or other financial barrier.
Private insurers are required to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. Private payer benefits are subject to specific plan policies. Check with individual insurance plans to determine what specific interventions are included and the extent to which these interventions are covered.
Resources for patients who do not have insurance coverage or who have limited coverage by their insurance carrier include the following:
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