CurrentkernfamilyhealthcarePolicy Letter 14 -006

Tobacco Cessation Services Coverage Criteria

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Governs required identification, assessment, counseling, medication coverage, and referral services for tobacco users among Kern Family Health Care (Medi-Cal) members, including special provisions for pregnant beneficiaries and pediatric prevention efforts.

Policy Summary

Payerkernfamilyhealthcare

PolicyTobacco Cessation Services Coverage Criteria

Policy CodePolicy Policy Letter 14 -006

Change TypeNo material change

Effective DateNov 1, 2014

Next Review Date

Key ActionDocument initial and annual tobacco use status in the medical record and complete the IHEBA (Staying Healthy Assessment) for new beneficiaries within 120 days of enrollment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial & annualtobacco use assessment frequency

FDA-approvedmedication coverage

Face-to-facepregnancy counseling min

60 dayspostpartum quit-line

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CurrentkernfamilyhealthcarePolicy Letter 14 -006

Tobacco Cessation Services Coverage Criteria

Customize your policy alerts

Sign up for kernfamilyhealthcare Policy Letter 14 -006 alerts

Get alerted when Policy Letter 14 -006 changes without checking for updates manually.

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Policy Summary

Payerkernfamilyhealthcare

PolicyTobacco Cessation Services Coverage Criteria

Policy CodePolicy Policy Letter 14 -006

Change TypeNo material change

Effective DateNov 1, 2014

Next Review Date

Key ActionDocument initial and annual tobacco use status in the medical record and complete the IHEBA (Staying Healthy Assessment) for new beneficiaries within 120 days of enrollment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Initial & annualtobacco use assessment frequency

FDA-approvedmedication coverage

Face-to-facepregnancy counseling min

60 dayspostpartum quit-line

Coverage Criteria for Tobacco Cessation

inv-01: Assessment and Identification

Covered when the following are implemented as required by DHCS:

Assessment and identification: Initial identification and annual assessment of tobacco use for each adolescent and adult member; complete the Individual Health Assessment (including the IHEBA/SHA) for all new beneficiaries within 120 days of enrollment; reassess tobacco use annually per the SHA periodicity; document tobacco use status in the medical record at every visit.120 days; annual

SHA periodicity governs re-administration

inv-02: Treatment Services

Covered interventions for tobacco users of any age:

Medications: Coverage of FDA‑approved tobacco cessation medications for non‑pregnant adults of any age, including over‑the‑counter medications when prescribed by a provider; beneficiaries are not required to provide proof of counseling to obtain medications.non-pregnant adults

Follow standard prescribing rules

Counseling modalities: Coverage of individual, group, and telephone counseling for members of any age who use tobacco products; providers and staff should use validated behavior change models (5 A's, 5 R's) and review SHA tobacco questions; refer beneficiaries to the California Smokers' Helpline or other comparable quit‑line services and, when available, use web or e‑referral systems.any age

Encourage Helpline e‑referral/web referral if available

inv-03: Pregnancy

Pregnancy-specific coverage and requirements:

Screening in pregnancy: Ask all pregnant beneficiaries if they use tobacco or are exposed to tobacco smoke; provide assistance with quitting throughout pregnancy and follow ACOG smoking cessation guidance before prescribing medications.pregnancy

Refer to ACOG guidance prior to prescribing

Counseling for pregnant beneficiaries: Offer at least one face‑to‑face tobacco cessation counseling session per quit attempt; counseling may be provided by or under the supervision of a physician authorized under state law.per quit attempt

Face‑to‑face is minimum

Postpartum counseling coverage: Refer pregnant beneficiaries who use tobacco to a tobacco cessation quit‑line (e.g., California Smokers' Helpline); quit‑line counseling services must be covered for 60 days after delivery plus any additional days needed to end the respective month.

inv-04: Prevention in Children and Adolescents

Pediatric prevention:

Prevention in children and adolescents: Primary care clinicians shall provide interventions, including education or counseling, to prevent initiation of tobacco use in school‑aged children and adolescents in accordance with the AAP Bright Futures periodicity and anticipatory guidance.school-aged

Follow Bright Futures schedule

No age-based exclusions apply to counseling: individual, group, and telephone counseling are covered for members of any age; providers should use validated behavioral models (the 5 A's or 5 R's) when delivering counseling and should review the SHA/IHEBA tobacco questions with beneficiaries to document status. For medications, the policy covers FDA‑approved tobacco cessation medications for non‑pregnant adults of any age, including over‑the‑counter products when prescribed; beneficiaries are not required to provide proof of counseling to obtain these medications from a pharmacist or other Medi‑Cal provider.

Referenced Diagnosis and Procedure Codes

Referenced diagnosis codesICD-10

ICD-10 (referenced)

Tobacco/Nicotine Dependence, and Secondhand Smoke Exposure (document references ICD-10 codes effective October 1, 2015)

Provider Actions and Billing Notes

Prior Authorization

Medications accessible without prior authorization

No prior authorization or proof of counseling is required for beneficiaries to obtain FDA‑approved tobacco cessation medications, including over-the-counter medications when prescribed.

Step Therapy

Step therapy not required

There are no step therapy requirements for tobacco cessation medications or services specified in this policy.

Documentation Required

Required documentation: IHEBA/SHA and tobacco use status

Background and Policy Context

Tobacco cessation services are mandated by the California Department of Health Care Services (DHCS) and Kern Family Health Care implements those requirements. Providers must perform routine identification and behavioral interventions: conduct an initial assessment and annual reassessment of tobacco use for adolescents and adults, complete the IHEBA/Staying Healthy Assessment (SHA) for new beneficiaries within 120 days of enrollment and follow the SHA periodicity for annual reassessment, and document tobacco use status at every visit. Providers must also refer tobacco users to the California Smokers' Helpline (or a comparable quit‑line) and are encouraged to use the Helpline's web or e‑referral systems. Special pregnancy guidance requires asking all pregnant beneficiaries about tobacco use and providing assistance throughout pregnancy, and postpartum quit‑line counseling must be covered for 60 days after delivery as specified by DHCS.

Definitions

IHEBA / SHA — definition and role

TermIndividual Health Education Behavioral Assessment (IHEBA) / Staying Healthy Assessment (SHA)

DefinitionThe IHEBA is the Individual Health Education Behavioral Assessment; the DHCS Staying Healthy Assessment (SHA) serves as the IHEBA.

Required timingComplete the IHEBA/SHA for all new beneficiaries within 120 days of enrollment; review or re-administer annually per SHA periodicity.

Role in careUsed to identify and document tobacco use status (initial and annual) and to guide counseling interventions.

Documentation requirementAsk tobacco users about current use and document tobacco use status in the medical record at every visit; SHA questions on tobacco should be reviewed with the beneficiary.