Coverage for Patient Services

Systematic barriers, such as concerns about insurance reimbursement or not knowing where to refer patients for tobacco cessation support have been identified as being detrimental to smoking cessation in oncology practice. Therefore, it is important to have systems in place to provide all tobacco users with information about quitting, including:

  • In-house cessation support
  • Referrals to quitlines (e.g., by fax referrals)
  • Referrals to community resources to support tobacco cessation (support groups, Internet resources)
  • Information on insurance reimbursement

Coverage for these treatments varies by insurer and state. Information on coverage, including coding, can be found below according to insurance type.

Overview of Tobacco Cessation Coverage by Insurance Type
Insurance StatusCoverage Information
Medicare
  • Evidence-based tobacco cessation counseling is covered
  • Part D covers FDA-approved cessation drug therapies; over-the-counter therapies are typically excluded
Medicaid
  • Comprehensive cessation benefits are covered for pregnant women with no cost sharing
  • As of January 1, 2014, all state Medicaid programs will be required to support all FDA-approved tobacco cessation medications without requiring co-pays
Private Insurance
  • Patient Protection and Affordable Care Act (ACA or health reform bill) requires all insurance plans to provide evidence-based tobacco cessation interventions
  • Providers should check with individual insurance plans for coverage specifics
No InsuranceOptions could include:
  • Quitlines (1-800-QUITNOW)
  • Online cessation resources
  • Flexible spending account
  • Employee assistance programs
  • Community resources
  • Out-of-pocket spending

Medicare

In 2010, the Department of Health and Human Services expanded Medicare coverage to include evidence-based tobacco cessation counseling, removing a barrier to treatment for all tobacco users covered by Medicare. Under the new coverage, an individual who uses tobacco and is covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare-recognized practitioner who can work with them on tobacco cessation. Payment is based on two Healthcare Common Procedural Coding System (HCPCS) codes:

  • G0375: Smoking and tobacco use cessation counseling visit; intermediate, more than three minutes and up to 10 minutes
  • G0376: Smoking and tobacco use cessation counseling visit; intensive, more than 10 minutes

Additional payment may be received based on the evaluation and management service (99201–99215, including modifier -25) provided on that same day and separately identifiable from smoking cessation counseling. Counseling which lasts fewer than three minutes is included in the standard physician visit and is not separately reported. Medicare beneficiaries are eligible for up to four counseling sessions for each attempt to quit and up to two attempts to quit are covered over a 12-month interval.

The ICD-9 code for Nicotine Dependence is 305.1. In addition to the two G-codes, alternative HCPCS codes include S9075 for smoking cessation treatment and S9453 for smoking cessation classes. Quitlines serve as an excellent free tobacco cessation resource that all patients can access, regardless of insurance status. The patient’s health record should document all services provided.

Medicare Part D has covered FDA-approved cessation drug therapies for eligible beneficiaries since 2006 as part of the prescription drug benefit; over-the-counter formulations of nicotine replacement therapies are generally excluded.

Medicaid

As per the Patient Protection and Affordable Care Act (PPACA or health reform bill), Medicaid tobacco cessation coverage has been expanded. As of 2010, all state Medicaid plans must cover a comprehensive cessation benefit for pregnant women with no cost-sharing.21 Beginning January 1, 2013, states that cover preventive services like tobacco cessation will receive increased federal reimbursement; as of January 1, 2014, all state Medicaid programs will be required to support all FDA approved smoking cessation medications without requiring co-pays or other financial barriers. Quitlines offer state-specific services Medicaid recipients can access free of cost.

Private Insurance

The PPACA bill also requires private health insurance plans to provide evidence-based tobacco cessation counseling and interventions to all adults and pregnant women. This requirement stems from the health reform bill’s inclusion of all United States Preventive Services Task Force (USPSTF) Grade A and B Recommendations in private insurance coverage; the provision of tobacco cessation strategies to adults and pregnant women is a USPSTF Grade A recommendation. Although physicians will need to check with insurance plans to determine what specific interventions are included and to what degree they are covered (e.g., how many counseling sessions are covered), the health reform bill requires screening and cessation interventions be provided with no co-payment or co-insurance.

Despite these regulations, whether and to what extent tobacco cessation will be covered is unclear at the time of this publication. Many private insurance plans cover medications for tobacco dependence but they vary in their policies regarding reimbursement. Regardless of coverage specifics, quitlines serve as an excellent free tobacco cessation resource that all patients can access.

No Insurance

For patients who either do not have insurance or who have insurance that does not cover tobacco cessation explicitly, other options include:

  • Quitlines (1-800-QUITNOW)
  • Online cessation resources (see Tables 4.1 and 4.2)
  • Flexible spending accounts (patients should see if tobacco cessation is an allowable expense)
  • Employee assistance programs (some employers will cover a quit attempt in their EAP)
  • Community resources (support groups, etc.)
  • Out-of-pocket spending