August 31, 2015

Todd Kiser, Insurance Commissioner

Utah Insurance Department
3110 State Office Building
Salt Lake City, UT 84114

Dear Commissioner Kiser:

We are joining with advocates and health care providers to call your attention to discrepancies in some Utah health exchange plans regarding the administration of tobacco cessation benefit coverage as mandated by Utah state law and the Affordable Care Act.

We, the undersigned, urgently request you provide guidance to Utah commercial insurers and health plans to clarify what tobacco cessation services/therapies must be covered to comply with both state and federal law, so Utahans can get the benefits that may not be available to them.

The Patient Protection and Affordable Care Act (ACA) provides clear language regarding tobacco cessation benefits, although some Utah insurers are attempting to find loop holes.

What does the Act say about tobacco cessation? It allows plans to continue using established medical management models, but there is no loophole to supersede the ACA that would authorize plans to add barriers such as expensive co-pays, prior authorization, step therapy and/or specialty tier costs which can prevent patient access and adherence to medical therapies that help tobacco users to quit. This is happening here in Utah.

What Should Plans Cover?

According to the ACA and federal guidance, all plans should cover a comprehensive tobacco cessation benefit:

  • At least four sessions of individual, group and telephone cessation counseling
  • All FDA-approved tobacco cessation medications (Nicotine patch, gum, lozenge, nasal spray and inhaler, bupropion and varenicline)
  • At least two quit attempts per year
  • No cost-sharing, like copays, coinsurance or deductibles
  • No prior authorization requirements

Since 2010, the ACA has required all private insurers (including self-funded employers) – with the exception of “grandfathered” plans – to cover certain preventive services without any patient cost sharing (Co-payments/co-insurance/deductibles). Insurers are required to provide coverage for evidence-based items or services that have a rating of “A” or “B” in the current recommendations of the United State Preventative Services Task Force (USPSTF), an independent panel of clinicians and scientists. An “A” or “B” letter grade indicates that the panel finds there is high certainty that the services have a substantial or moderate net benefit.

Counseling and Interventions to Prevent Tobacco Use and Tobacco-Caused Disease in Adults is an “A” rated service and is required under federal law. Specifically, all adults age 18 and older should be screened for tobacco use and those who use tobacco products, should be provided access to tobacco cessation interventions. These intervention should include: tobacco counseling (group, individual and telephonic) in combination with pharmacotherapy, that includes all FDA approved tobacco cessation medications.

The majority of marketplace plans are not only falling short of the guidelines set by the federal government, but more importantly, they are also missing a critical opportunity to help millions of Americans quit smoking. Evidence also suggests that smoking rates of people enrolled in marketplace plans are high, which means they are missing the chance to offer full cessation benefits to those who may need it the most. In Utah, approximately 190,000 adults and more than 14,000 middle and high school students

are current smokers. The Centers for Disease Control and Prevention estimates that morethan 1,150 Utahns die each year from tobacco-related causes. Utahns who are not covered by health insurance are more likely to report cigarette smoking than Utahns who have health insurance. At 17.2%, the smoking rate among Utah adults without health insurance is almost double the smoking rate of Utah adults with insurance (9.0%). More than one fourth (27.5%) of Utah smokers have no health insurance.1, 2

As such, local and national health and patient advocacy organizations ask Utah’s Insurance Commissioner to immediately provide guidance to insurers and plans clarifying that “tobacco cessation interventions” include all forms of evidence-based counseling and FDA-approved medications and that these interventions will be covered whether or not they are delivered during an office visit.

Our organizations welcome the opportunity to meet with you and talk more about these requirements, answer questions and tell you more about other efforts in Utah designed to encourage and assist tobacco users in quitting. Please contact Jamie Riccobono at the American Lung Association at 801-971-9115 to schedule an appointment or to discuss further.

Thank you for your consideration in implementing this important health benefit to all Utahans.

Sincerely,

American Cancer Society Cancer Action Network

American Heart Association

American Lung Association in Utah

Utah Department of Health Tobacco Prevention and Control

Utah Pride Center

1Utah Department of Health. Behavioral Risk Factor Surveillance System (BRFSS), 2011-2013. Salt Lake City: Utah Department ofHealth, Center for Health Data.

2Utah Department of Health. IBIS-PH Dataset Queries, Population Estimates for 2013. Retrieved on November 5, 2014 from