Coverage of Cessation Services for Medicare Beneficiaries: An “Almost” Success Story

2. Coverage of Cessation Services for Medicare Beneficiaries: An “Almost” Success Story Linda A. Bailey Executive Director, NAQC Smoking Cessation Leadership Center 2005 Annual Meeting April 6-7, 2005 * Princeton, NJ Robert Wood Johnson Foundation

3. The “Almost” Success Story March 22 CMS decision to cover: • 2 quit attempts per year; 4 intermediate or intensive sessions at each attempt • Outpatient or in-patient (not 305.1) tx • No group, quitline or web-based tx • Prescription-only meds covered (Zyban, nicotine inhaler and nasal spray), effective January 1, 2006

4. Overview • Background on the CMS Decision on Coverage of Cessation Services • Analysis of Final Decision by CMS • Moving from “Almost Success” to a “Complete Success”

5. Background – CMS Decision June 2004: PFP request for expanded coverage for tobacco cessation counseling accepted by CMS and posted for 30-day comment Dec 2004: CMS’ proposed decision posted for 30-day comment period March 2005: Final CMS decision memo published

6. Analysis of CMS Proposal and Final Decision CMS uses science-based analysis to determine: • Is the service reasonable and necessary? • Will the intervention improve the net health outcome of beneficiaries?

7. Analysis of CMS Proposal and Final Decision CMS Findings: • PHS Guideline (2000) provides a strong basis for allowing coverage • Training is necessary to provide effective counseling, but national standard does not exist • Smoking cessation counseling by HC practitioners (authorized in Part B) will result in effective cessation

8. Analysis of CMS Proposal and Final Decision CMS Findings (continued): 4. Dose-response relationship exists but no evidence on best dose for Medicare pop, so CMS will use PHS Guideline on session # & intensity 5. Inpatient stay for 305.1 (tobacco use disorder) is not reasonable and necessary

9. Analysis of CMS Proposal and Final Decision 10 ISSUES ADDRESSED: • Eligible beneficiaries * FDA-app meds • Qualified providers * Training & cert. • Session length * Inpatient tx • Group treatment * Quitline tx • Web-based tx * Pay & codes

10. Moving from “Almost Success” to “Complete Success” What’s missing from Medicare coverage? • CMS did not include “all smokers” as eligible. 2. CMS excluded group tx and quitline tx from qualified service providers. 3. CMS did not allow for non-prescription FDA-approved meds.

11. Moving from “Almost Success” to “Complete Success” Problems/Solutions: • Legislative authority only allows payment of services (1) for the sick and injured; (2) by providers on Part B list; and (3) prescription drugs (2006) • Administrative decision to only allow payment for “in-person” tx

12. Moving from “Almost Success” to “Complete Success” Will a complete success happen? • Flexibility under Medicare Advantage Plan • CMS Medicare Stop Smoking study + • Feds could use a success on Medicare Is it important to push for complete success? • Group/quitlines effective, increase reach • Other payers will go as Medicare goes

13. For Additional Information Email: LBailey@americanlegacy.org For quitline info: www.NAQuitline.org For CMS decision info: www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=130