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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
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
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”
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
Analysis of CMS Proposal and Final Decision
CMS uses science-based analysis to determine:
1. Is the service reasonable and necessary?
2. Will the intervention improve the net health outcome of beneficiaries?
Analysis of CMS Proposal and Final Decision
CMS Findings:1. PHS Guideline (2000) provides a
strong basis for allowing coverage2. Training is necessary to provide
effective counseling, but national standard does not exist
3. Smoking cessation counseling by HC practitioners (authorized in Part B) will result in effective cessation
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
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
Moving from “Almost Success” to “Complete
Success”
What’s missing from Medicare coverage?
1. 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.
Moving from “Almost Success” to “Complete
Success”
Problems/Solutions:
1. 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)
2. Administrative decision to only allow payment for “in-person” tx
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
For Additional Information
Email: [email protected]
For quitline info: www.NAQuitline.org
For CMS decision info:www.cms.hhs.gov/mcd/
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