Exemplar Tobacco Cessation Coverage: Recommended Summary Plan Description Language for Insured Employers

The following coverage document was created and shared by the Colorado Department of Public Health & Environment.

Effective January 1, 2010, HB 09-1204 requires that all individual and group health insurance policies offered to residents of Colorado shall provide coverage for preventive health care services that receive an A or B recommendation from the United States Preventive Services Task Force (USPSTF). Coverage shall not be subject to policy deductible or coinsurance. Copayments consistent with the overall benefit plan are permitted. Likewise, under the federal Patient Protection and Affordable Care Act, effective September 23rd, 2010, all non-grandfathered employers offering coverage must offer all USPSTF A and B recommendations. However, the federal requirements do not permit any member costsharing for these services. The benefits outlined below are consistent with the Affordable Care Act.

Screening

Coverage: Routine screening for tobacco use is a covered benefit.

Frequency: Screening is conducted on a regular basis.

Counseling

Coverage: Counseling (telephonic or face-to-face through individual or group sessions) is a covered benefit for tobacco dependence treatment.

Restrictions: Counseling is offered but not required as a condition of receiving other cessation benefits.

Frequency: Multiple courses of counseling are offered per calendar year with no requirement regarding number of sessions or duration of sessions.

Evidence: There is a dose-response relationship between the number of counseling sessions and quit rates. More sessions increase quit rates with evidence that counseling up to 300 minutes per course of treatment has the greatest effectiveness.

Pharmacotherapy

Coverage: All FDA-approved nicotine replacement products and tobacco cessation medications (over the counter and prescription) are covered.

Restrictions: Provision of medications is not linked to enrollment in counseling or coaching.

Frequency: At least two courses of treatment per year.*

Evidence: Pharmacotherapy has demonstrated quit rates of up to 44 percent. Combining counseling (telephonic or face-to-face) with pharmacotherapy is even more effective.

Lifetime limits

Coverage: Benefits cover at least two quit attempts a year with no lifetime limit on counseling or pharmacotherapy.*

Restrictions: Coverage is not tied to diagnosis of a tobacco-related medical condition.

Patient out-of-pocket

Covered treatment should include no employee cost-sharing.

Evidence: Research has demonstrated that the cost of treatment keeps people from accessing treatment. Conversely, free and accessible treatment increases participation and overall quit rates.

Created 12/23/2010

*USPSTF is silent with respect to frequency and payment so the Tobacco Cessation and Sustainability Partnership deferred to the evidence-based Centers for Disease Control recommendations regarding frequency and payment.