MassHealth will reimburse enrolled MassHealth physicians, community health centers (CHCs), and acute outpatient hospitals (OPDs) who provide smoking cessation counseling, and pharmacotherapy services.
Did you know that 36% of MassHealth members are smokers? According to the Massachusetts Department of Public Health, that is almost double the 19.4% smoking rate of the general state population. MassHealth and its associated Managed Care Organizations (MCOs) offer a benefit to help MassHealth members quit smoking or using tobacco. Providers should bill the MassHealth member's MCO when providing services to MCO plan members. MassHealth MCOs include BMC HealthNet Plan, Fallon Community Health Plan, Neighborhood Health Plan, and Network Health.
Since stopping tobacco use may require multiple attempts, this benefit is designed to allow members and providers as much flexibility as possible. Over the course of a 12-month cycle, members may use up to 16 counseling sessions in any combination of group or individual face-to-face sessions, including two intake/assessment sessions. Prior authorization is required for counseling sessions beyond this limit.
Members may obtain a 90-day supply of nicotine patch, gum, lozenge, or other FDA approved medications for smoking cessation; the nicotine inhaler and nasal spray require prior authorization. A maximum of two 90-day treatment regimens are covered per 12-month cycle. Additional supplies of nicotine replacement therapy (NRT) medication require prior authorization. Please see the MassHealth Drug List for further details about other drugs used for tobacco cessation. The MassHealth Drug List can be found at www.mass.gov/druglist. It can also be accessed from the MassHealth Pharmacy Program home page at www.mass.gov/masshealth/pharmacy.
Member Eligibility for Tobacco Cessation Benefit
Members eligible to receive physician services, community health center services, acute outpatient hospital services and pharmacy services are covered for tobacco cessation services, based on their MassHealth coverage type as described at 130 CMR 450.105.
Providing Tobacco Cessation Counseling
Physicians, registered nurses, physician's assistants, nurse practitioners, and nurse midwives are authorized to provide tobacco cessation counseling. Tobacco cessation counselors who have received the appropriate training may also provide counseling (as designated in MassHealth Regulations available online at www.mass.gov/eohhs/gov/laws-regs/masshealth). Any non-physician providers must be under the supervision of a physician, except independent nurse practitioners and independent nurse midwives providing tobacco cessation counseling services directly.
If you have any questions about this benefit, contact MassHealth Customer Service at 1-800-841-2900. Also please see the MassHealth Fact Sheet for Providers.
Provider Resources for tobacco cessation services and materials and training for tobacco cessation counselors are available at www.quitworks.com, The Office of the Surgeon General, University of Massachusetts Medical School, TobaccoCME.com, and The Agency for Healthcare Research and Quality.
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This information is provided by MassHealth.