Federal Cessation Treatment Coverage Methodology

The federal cessation treatment coverage criteria used in the American Lung Association's "State of Tobacco Control" 2024 report is based on the coverage of tobacco cessation treatments provided by the federal government through its four main public insurance programs:

1. Medicare (for individuals over age 65),
2. Medicaid (for low-income individuals and families),
3. TRICARE (for members of the military and their families), and
4. Federal Employee Health Benefits Program (for federal employees and their families).

A fifth category covers federal requirements for tobacco cessation treatment coverage in state health insurance marketplaces under the Affordable Care Act. Providing help to quit through these programs and state health insurance marketplaces will reach large numbers of individuals who use tobacco, improve health, prevent unnecessary death, save taxpayer money and set an example for other health plans. The federal government must lead by example and cover a comprehensive benefit for everyone to whom it provides health care.

Medicare (4 points)

Target is all Medicare recipients have easy access to a comprehensive cessation benefit.

• +4 points: All Guideline-recommended medications and counseling are covered.
• +3 points: At least 4 medications and 1 type of counseling are covered.
• +2 points: At least 2 medications and 1 type of counseling are covered.
• +1 point: At least 1 treatment is covered.
• +0 points: No coverage.

Medicaid (4 points)

Target is all Medicaid enrollees have easy access to a comprehensive cessation benefit.

• +4 points: All Guideline-recommended medications and counseling are required to be covered.
• +3 points: At least 4 medications and 1 type of counseling are required to be covered.
• +2 points: At least 2 medications and 1 type of counseling are required to be covered.
• +1 point: At least 1 treatment is required to be covered.
• +0 points: No required coverage.

TRICARE (4 points)

Target is all TRICARE enrollees have easy access to a comprehensive cessation benefit.

• +4 points: All Guideline-recommended medications and counseling are covered.
• +3 points: At least 4 medications and 1 type of counseling are covered.
• +2 points: At least 2 medications and 1 type of counseling are covered.
• +1 point: At least 1 treatment is covered.
• +0 points: No coverage.

Federal Employee Health Benefits (FEHB) (4 points)

Target is all federal employees & dependents have easy access to a comprehensive cessation benefit.

• +4 points: All Guideline-recommended medications and counseling are covered.
• +3 points: At least 4 medications and 1 type of counseling are covered.
• +2 points: At least 2 medications and 1 type of counseling are covered.
• +1 point: At least 1 treatment is covered.
• +0 points: No coverage.

Federal Requirements for State Health Insurance Marketplaces (4 points)

Target is all plans in marketplaces cover a comprehensive tobacco cessation benefit.

• +4 points: All Guideline-recommended medications and counseling are required to be covered.
• +3 points: Administration releases guidance outlining coverage of a comprehensive tobacco cessation benefit as a preventive service.
• +2 points:  Administration requires that all plans sold in the State Health Insurance Marketplaces cover tobacco cessation treatment as part of the preventive services requirement.
• +1 points: Administration proposes new regulations that no longer require all plans in the State Health Insurance Marketplaces to provide tobacco cessation treatment.
• +0 points: Administration finalizes new regulations or issues guidance that no longer require all plans in the State Health Insurance Marketplaces to provide tobacco cessation treatment.

Bonus Points: 1 bonus point in each category is awarded if coverage is provided with minimal barriers to access. Common barriers to access include required counseling, prior authorization, stepped care therapy, cost sharing, duration limits, annual limits and lifetime limits to tobacco cessation treatment.