Gaps in Coverage within Public and
Private Insurance Plans Continue to
Impede Comprehensive Addiction Care
Screening and Interventions for Risky
Substance Use. Recent developments in
Medicare and Medicaid reimbursement have
begun to remove some of the cost barriers that
health professionals faced in routinely screening
their patients for risky use of addictive
substances and conducting early interventions
when necessary.^106
For example, the U.S. Department of Health and
Human Services’ Centers for Medicare and
Medicaid Services (CMS) adopted Medicaid
billing codes for screening and brief intervention
services; in January 2007, these codes became
effective.^107 The Medicaid codes cover these
services related to alcohol and other drugs
(excluding nicotine).^108 These codes are
available for health care providers in individual
states to use but there is no requirement for
providers to use the codes. Individual states
determine which services are reimbursed and, to
be operational, states have to enable the billing
codes; however, many have not done so.* 109
With regard to smoking, the only screening
services that states explicitly are required to
provide are those that fall under the Early and
Periodic Screening, Detection and Treatment
(EPSDT) Program--the child health component
of Medicaid which is required for each state to
finance appropriate and necessary pediatric
services, including tobacco cessation services
for youth; as of 2000,† 15 states explicitly
require providers to screen youth for tobacco
use.^110 (See next section on treatment for
information about coverage for smoking
cessation services.)
In 2008, CMS adopted Medicare billing codes
for structured assessments‡ and brief
intervention services related to the risky use of
alcohol and other drugs (excluding nicotine) for
- And these codes do not cover screening and
intervention services for all addictive substances.
† Most recent available data.
‡ Structured assessments involve the use of validated
tools such as AUDIT or DAST (see Appendix H).
patients who show signs/symptoms of
substance-related problems.^111 These services
were reimbursed only when reasonable and
necessary to diagnose or treat illness or injury.^112
In October 2011, CMS determined that
Medicare would provide coverage in primary
care settings§ for preventive annual alcohol
screening** of all patients and up to four brief,
face-to-face interventions for Medicare
beneficiaries who screen positive for risky
alcohol use but who do not meet clinical criteria
for addiction involving alcohol.^113 Medicare
does not reimburse for population-wide
screening and brief interventions to address the
risky use of illicit and prescription drugs because
it is not yet recommended by the U.S.
Preventive Services Task Force (see Chapter
IV).†† 114 Although there are no specific
Medicare codes for general tobacco use
screening, questions about tobacco use are
considered part of the medical history to be
collected, for example, during the Initial
Preventive Physical Examination for those new
to Medicare.^115 As of August 2010, Medicare
does cover preventive tobacco cessation
counseling for smokers who do not present with
signs or symptoms of tobacco-related disease.
The benefit includes two individual tobacco
cessation counseling attempts per year, with
each attempt consisting of up to four sessions.^116Despite the facts that the American Medical
Association (AMA) has published Current
Procedural Terminology (CPT) codes for
screening for tobacco use‡‡ 117 and risky use of
alcohol and other drugs^118 and that most private
insurance plans cover these services,^119 patients
are not routinely screened for risky use or
provided brief interventions if indicated. A
2009 survey found that very few claims have
been paid by commercial insurance plans for§ Including outpatient hospital settings.
** But not for other substances. Medicare allows
providers to choose any screening tool that is
appropriate for their clinical population and setting.
†† Medicare does cover structured assessments to
evaluate and provide interventions for patients who
exhibit symptoms of addiction involving drugs.
‡‡ CPT codes for tobacco screening include the codes
for “health and behavior assessment” and other
preventive medicine services.