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Reducing Out-Of-Pocket Costs for Evidence-Based Cessation Treatments

Reducing out-of-pocket costs for evidence-based cessation treatment involves implementing policies to offer new benefits or change the level of benefits offered (for example, reduced copayments). The Community Guide states that reducing costs for cessation treatments increases the number of individuals who quit using tobacco.

Rural residents, especially those with lower incomes, are more likely to be uninsured or underinsured and to rely on public sources of health insurance. One study found that focus group participants in a rural, Appalachian Kentucky community reported wanting to use pharmaceutical aids during their quit attempts, but found the costs prohibitive. These participants reported that they would be more likely to use medications if insurance covered the cost. A report funded by the Robert Wood Johnson Foundation found that the demand for nicotine replacement therapy increases when it is free or covered by insurance and suggests that the cost of medication is a barrier to use.

Currently, federal laws and rules require almost all types of health insurance plans to cover tobacco use counseling and interventions without cost-sharing. These services may include screening for tobacco use, tobacco counseling sessions, and all tobacco cessation medications (including both prescription and over-the-counter medications) that are approved by the Food and Drug Administration (FDA).

Examples of Programs that Reduce Out-Of-Pocket Costs

  • Implemented in January 2011, the cessation benefits for federal employees serves as a model of comprehensive, evidence-based coverage for tobacco users. Services with lifetime coverage include counseling, FDA-approved tobacco cessation medications, and 2 quit attempts per year. Beneficiaries do not pay copays and coinsurance costs for covered cessation services.
  • The Massachusetts Medicaid Cessation Benefit has led to an increase in use of cessation treatments, reduced smoking rates, improved health outcomes, and decreased medical costs among beneficiaries. These benefits were especially effective at improving outcomes among vulnerable, underserved, and hard-to-reach populations.
  • Oklahoma's Medicaid program, SoonerCare, identified the cost of medication copayments and the burden of prior authorization as barriers that prevented Medicaid enrollees from accessing tobacco cessation treatments. The Oklahoma Health Care Authority, the Oklahoma State Department of Health, and the Oklahoma Tobacco Settlement Endowment Trust worked together to make a case for decreasing these barriers to treatment. On September 1, 2014, SoonerCare eliminated tobacco cessation medication copayments and prior authorization requirements.
  • The Vermont Department of Health Tobacco Control Program conducted research that found rural Vermonters of low socioeconomic status were more likely to use tobacco products than the overall population. In order to help increase access to effective tobacco cessation services for this population, the program worked with the Vermont Medicaid office to activate CPT codes for tobacco counseling for individuals and groups, and engages in outreach to providers to increase the code use.

Considerations for Implementation

Rural program planners may need to raise awareness of tobacco cessation benefits among tobacco users and healthcare providers in their communities. Many people are unaware of their options and cessation benefits are consistently underused. Proactive promotion of cessation coverage will increase the chances that tobacco users and health providers access these benefits.

The Centers for Disease Control and Prevention funded the American Lung Association to provide technical assistance to state tobacco control programs in their efforts to promote comprehensive coverage of cessation treatments among private and public insurers. The American Lung Association maintains a database that demonstrates smoking cessation coverage per state.

Program Clearinghouse Examples

Resources to Learn More

Cessation Interventions, Best Practices for Comprehensive Tobacco Control Programs – 2014
Document
Cessation interventions are one component of comprehensive tobacco control programs. This chapter, from CDC's evidence-based guide on comprehensive, population-based approaches to tobacco control, presents information, examples, and resources to guide cessation activities with the goals of promoting systems change, expanding insurance coverage and use of cessation services, and supporting quitlines.
Organization(s): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health
Date: 2014

Coverage for Tobacco Use Cessation Treatments
Document
This fact sheet gives a brief overview of tobacco's health and economic burden, available cessation treatments, and the current status of cessation coverage for private and public insurance.
Organization(s): Centers for Disease Control and Prevention
Date: 5/2014

An Evidence-based Cessation Strategy Using Rural Smokers' Experiences with Tobacco
Document
This article focuses on the experiences of current and former smokers living in an economically disadvantaged area of rural Kentucky.
Author(s): Butler, K., Hedgecock, S., Record, R., Derifield, S., McGinn, C., Murray, D., & Hahn, E.J.
Citation: The Nursing Clinics of North America,47(1), 31–43
Date: 3/2012

Reimbursement for Smoking Cessation Therapy: A Healthcare Practitioner's Guide, 3rd Edition
Document
This guide gives an overview of tobacco cessation treatments, public and private sector initiatives, and information on obtaining reimbursement.
Organization(s): Professional Assisted Cessation Therapy (PACT)

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage — United States, 2014–2015
Document
This article describes the state of Medicaid tobacco cessation coverage in the United States and barriers to accessing treatments.
Citation:Morbidity and Mortality Weekly Report (MMWR), 64(42),1194-9
Organization(s): Centers for Disease Control and Prevention
Date: 10/2015

Treating Tobacco Use and Dependence: 2008 Update
Document
These resources are geared toward clinicians, system decision-makers, and tobacco users.
Organization(s): Agency for Healthcare Research and Quality
Date: 6/2015

You Can Afford to Quit Smoking
Document
This case study provides an overview of federal employees' health benefits for tobacco cessation. Experiences related to program implementation, communication, and next steps are discussed.
Organization(s): U.S. Office of Personnel Management, Partnership for Prevention
Date: 6/2014