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MEDICARE COVERAGE
The Center for Medicare and Medicaid Services (CMS) has published several documents with information related to the new Medicare coverage of smoking cessation counseling (coverage of medications will begin January 2006):
CMS "Medlearn Matters: Information for Medicare Providers" #MM3834 provides information about the Medicare coverage of smoking cessation counseling: www.cms.hhs.gov/MLNMattersArticles/downloads/MM3834.pdf
"CMS Manual: Publication 100-03 Medicare National Coverage Determinations, Transmittal 36, May 20, 2005, Subject: Smoking and Tobacco-Use Cessation Counseling" details of coverage: www.cms.hhs.gov/Transmittals/downloads/R36NCD.pdf
"CMS Manual: Publication 100-04 Medicare Claims Processing, Transmittal 562, May 20, 2005, Subject: Smoking and Tobacco-Use Cessation Counseling Services" provides billing/coding details: www.cms.hhs.gov/Transmittals/downloads/R562CP.pdf
"Smoking and Tobacco-Use Cessation Counseling Services" is a CMS information brochure for physicians, providers, suppliers and other health care professionals: www.cms.hhs.gov/MLNproducts/downloads/smoking.pdf
MEDICAID COVERAGE/REIMBURSEMENT
Virginia Department of Medical Assistance Services (DMAS) manuals describe available coverage and provide billing information related to smoking cessation counseling and medications:
DMAS BabyCare Manual
"Covered Services and Limitations" chapter indicates that the BabyCare Program offers expanded prenatal services for any pregnant woman that includes "Smoking Cessation." Referrals for Expanded Prenatal Services may occur at any time during the pregnancy by either the primary care provider or the care coordinator: http://websrvr.dmas.virginia.gov/manuals/BC/chapter4_bc.PDF
"Provider Participation Requirements" chapter indicates that providers may have courses and patient education instructors approved for Medicaid reimbursement and the patient education courses that can be offered to a recipient include smoking cessation classes (see pages 5-7 for details): http://websrvr.dmas.virginia.gov/manuals/BC/chapterii_bc.pdf
"Billing Instructions" chapter contains billing details, including codes and reimbursement rates: http://websrvr.dmas.virginia.gov/manuals/BC/chapterV_bc.PDF
DMAS Community Mental Health Rehabilitative Services Manual
"Covered Services and Limitations" chapter (Page Revision Date 8/25/05), in the section on Expanded Prenatal Services (BabyCare) - Substance Abuse Treatment Services for Pregnant and Postpartum Women, includes in the list of "Required Activities" (a service or activity that must be provided to eligible women) "smoking cessation classes (if needed)" (see page 36): http://websrvr.dmas.virginia.gov/manuals/CMHS/Chapter4_cmhrs.pdf
DMAS All Manuals
"General Information" chapter (under General Exclusions, pages 8-10), includes as one of the examples of non-covered services "Smoking cessation programs." websrvr.dmas.virginia.gov/manuals/General/I_gen.pdf
DMAS Pharmacy Manual
"Covered Services and Limitations" chapter (Page Revision Date 12/22/04), in the section on coverage of over-the-counter drugs (pages 14 & 15) includes "Nicotene (sic) Cessation" in the list of specific therapeutic categories covered when used as less costly alternatives to prescription drugs: websrvr.dmas.virginia.gov/manuals/RX/chapteriv_rx.pdf
DMAS "Virginia Medicaid Covered Over the Counter Products as of December 6, 2005"
Included on this list are generic nicotine patches, nicotine gum and nicotine lozenge. To access, cut and paste this URL: www.dmas.virginia.gov/downloads/pdfs/pharm-OTC_%20list_12-05.pdf or click here.
"State Medicaid Coverage for Tobacco-Dependence Treatments -- United States, 1994-2001"
May 30, 2003 Morbidity and Mortality Weekly Report (MMWR), Volume 52, Number 21, pages 496-500 data for Virginia indicates that the state Medicaid program is aware of the PHS clinical practice guideline for treating tobacco use and dependence but is not using the guideline, does not require documentation of tobacco use status, does not require PHS counseling protocols to be used, has not provided support to providers, and has not informed smokers of coverage (see Table 2). Data about coverage in Virginia indicates that Medicaid covers the following medications: nicotine nasal spray (since 1996), nicotine inhaler (since 1997) and Zyban (since 1997): www.cdc.gov/mmwr/preview/mmwrhtml/mm5221a3.htm
The following is a copy of an e-mail message sent in response to an inquiry about MMWR data:
Subj: Medicaid Coverage of NRT & Zyban
Date: 7/24/2003 2:13:28 PM Eastern Daylight Time
From: BClark@dmas.state.va.us
This is in response to an inquiry that was addressed to Nancy Malczewski regarding the topic above. The response was prepared by our Medical Director, Dr. N. Moses Adiele:
If medical necessity is established, DMAS will pay even for the adult client. For example, DMAS will not pay to help any client (including children) to stop chemical dependency if there is no medical complication (mental or physical) of the habit. However, DMAS will pay to treat or correct the dependency if the treatment of the habit is necessary to manage or correct a medical complication. The key here is "medical complication, not dependency or age." Even if the client's dependency is corrected in the process of treating the medical complication, the reason for payment must be a medical complication and not the dependency.
Bernadette T. Clark
Freedom of Information Act Coordinator DMAS
600 E. Broad St., Suite 1300, Richmond, VA 23219
Phone: (804) 371-6391, Fax: (804) 371-4981
E-mail: bclark@dmas.state.va.us
Agency Web-site: www.dmas.state.va.us
APTNA is continuing to seek clarification of Medicaid coverage for smoking cessation counseling and medications, including details on billing and accessing covered services/medications. Information will be posted to this website when it is obtained.
National Partnership to Help Pregnant Smokers Quit
Website provides information and links relating to Medicaid coverage for cessation services, as well as other resources.
www.helppregnantsmokersquit.org/vp/channels/medicaid_resources.aspx
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