Tobacco Cessation and the Affordable Care Act Jennifer Singleterry Director, National Health Policy American Lung Association Background on ACA 1
Acronyms ACA = Affordable Care Act (healthcare reform) HHS = U.S. Dept. of Health & Human Services EHB = Essential Health Benefits CMS = Centers for Medicare and Medicaid Services USPSTF = United States Preventive Services Task Force Federal Poverty Line = FPL Persons in family FPL 138% of FPL 400% of FPL 1 $11,170 15,415 44,680 2 15,130 20,879 60,520 3 19,090 26,344 76,360 4 23,050 31,809 92,200 Traditional Medicaid Medicaid Expansion Exchanges 2
The Uninsured Who are the uninsured post-2014? < 100% FPL in states that don t expand Medicaid Childless adults, parents, disabled Choose to pay penalty rather than buy insurance young invincibles, anti-obamacare Legal immigrants <100% FPL caught in Medicaid waiting period Illegal immigrants Unreachables Timeline 2010 2011 2012 2013 2014 2015 2016 Requirements for private insurance, Medicare Implementation work, regulations October 1: Open enrollment in marketplaces (and Medicaid) begins January 1: Coverage through marketplaces (and Medicaid) begins November: Open enrollment begins again HHS to re-evaluate marketplaces 3
ACA: Hot Topics Lawsuits Upcoming enrollment period Problems with exchanges Medicaid expansion Background on Tobacco Cessation 4
Comprehensive Benefit 7 medications 5 NRTs Bupropion Varenicline 3 types of counseling Individual (face-to-face) Group Phone Easy to access/no limits Cost-sharing Prior authorization Duration limits Yearly or lifetime limits Dollar limits Stepped care therapy Required counseling Barriers to Access 5
Preventive Services & the ACA Preventive Services Private/employersponsored insurance plans (not grandfathered) Plans in state exchanges Preventive Services = required coverage, with no cost-sharing Small group and individual plans Medicaid expansion plans 6
U.S. Preventive Service Task Force An independent, volunteer panel of national experts in prevention and evidence-based medicine Make evidence-based recommendations for clinical preventive services for clinicians Assigns each recommendation a letter grade based on the strength of the evidence and balance of benefits and harms (A, B, C, or D grade, or I statement) Preventive Services Cancer screenings New B recommendation for lung cancer screenings Immunizations Blood pressure screenings Cholesterol screenings STI counseling 7
Tobacco A Grade: Counseling and Interventions Adults Pregnant women B Grade: Education and Brief Counseling for Prevention School-aged children & adolescents Tobacco Cessation FAQ 4 sessions of individual, group or phone counseling 90 days of 1 of the FDA-approved smoking cessation medications, when proscribed No cost-sharing No prior authorization At least 2 quit attempts per year 8
Tobacco Cessation FAQ Some interpret the FAQ as still allowing flexibility Plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service. A plan will be considered to meet the requirement, if for example, it covers Some States are Taking Action State insurance regulators can interpret the FAQ strictly and require plans to follow it Illinois Kansas Washington New Mexico 9
Coverage & Coverage Requirements Traditional Medicaid Tobacco Cessation September 2010: comprehensive tobacco cessation benefit required for pregnant women January 1, 2014: States are no longer able to exclude tobacco cessation medications What will this mean in implementation? Watch barriers, preferred drug lists/formularies 10
What are States Doing? Only 2 states cover a comprehensive benefit for traditional Medicaid: Indiana, Massachusetts 7 more cover everything except phone counseling: Connecticut, Maine, Minnesota, Nevada, Ohio, Pennsylvania, Vermont All states have barriers to coverage Nevada All tobacco cessation medications are covered Group and individual counseling covered with a mental health diagnosis 90 days per quit attempt 2 quit attempts per year Prior authorization required for all medications Copays required 11
What Can You Do? Find out what your state covers for tobacco cessation: www.lung.org/cessationcoverage Advocate for removal of barriers Work with Medicaid to make the benefit easy to understand Promote the benefit to Medicaid enrollees Provider education 12
Medicaid Expansion: Coverage Required Essential Health Benefit A and B Preventive Services FAQ guidance Prescription drugs At least one drug per category What States are Doing Preliminary research shows most states are incorporating the Medicaid expansion population into already-existing Medicaid coverage Tobacco cessation benefits mirror traditional Medicaid so lots of variance Some states should be removing copays if this is the case 13
Nevada Newly eligibles are all adults Incorporating expansion population into current Medicaid program This means newly eligibles will have access to an almost comprehensive cessation benefit! How are they dealing with prior authorization and copay requirements? What Can You Do? Advocate for Medicaid expansion Answer questions about integrating traditional and expansion Medicaid Push Medicaid to remove barriers as they are integrating benefits Promote cessation to the newly enrolled 14
State Exchanges Exchanges: Coverage Required Essential Health Benefit A and B Preventive Services FAQ Guidance Prescription Drugs At least one drug per category or as many as benchmark plan 15
What are States Doing? National-level information is scarce State regulator actions to enforce the cessation FAQ would affect the exchanges Nevada Benchmark Plan: Health Plan of Nevada, Inc. Smoking cessation drugs: 0 So standard for other plans is at least 1 Preventive services: covered??? 16
What Can You Do? Find out what your benchmark plan covers for tobacco cessation Survey exchange plans to see what they are covering for tobacco cessation make results public, and give to providers Reach out to exchange plans re: cessation FAQ Reach out to health insurance commissioner re: cessation FAQ Employer-Sponsored Insurance Grandfathered vs. non-grandfathered Non-grandfathered plans have been required to cover preventive services with no cost-sharing since 2010 New FAQ guidance No other coverage requirements 17
What are Plans and Employers Doing? National-level data is scarce, and near impossible State regulator actions to enforce the cessation FAQ would affect some of these plans Anecdotal evidence is showing that coverage being offered is NOT comprehensive and NOT uniform Nevada Any experiences to share? 18
What Can You Do? Survey plans in your state/area to see what they are covering for tobacco cessation Survey major employers in your area to see what they are covering for tobacco cessation Reach out to plans & employers re: cessation FAQ Provider education Medicare (Pre-ACA) Individual counseling and prescription medications are covered for tobacco cessation Added prevention visit No new requirements for preventive services Requires no cost-sharing for preventive services that are covered 19
Other Issues/Programs Tobacco Surcharges Variation in insurance premiums based on a policyholder s tobacco use AKA tobacco premiums, premium/rate differentials, non-smoker discounts ACA allows surcharges of up to 50% for tobacco use in small group & individual markets No restrictions for large group/self insured markets 20
Tobacco Surcharges Punitive measures are not a proven effective cessation method We already know what works why try an unproven method? Tobacco surcharges will make insurance unaffordable for tobacco users and their families No one wants tobacco users to be uninsured What are States & Plans Doing? States can prohibit or limit tobacco surcharges to smaller than 50% in individual and small group markets 11 states have done this One study showed most plans are not charging full allowed amount 21
Nevada Has not limited or prohibited surcharges Experiences to share? What Can You Do? Encourage state policymakers to prohibit surcharges Reach out to health insurance commissioner, find out what is being charged in your state/area Also play around on www.healthcare.gov Reach out to plans & employers, encouraging them not to use surcharges, or at least cover a comprehensive cessation benefit if they do 22
Prevention and Public Health Fund Started at $500 million in 2010. Increases incrementally to $2 billion in 2015. Purpose: provide vital funds for public health and wellness programs Activities: Quitline funding Tips from Former Smokers Community Transformation Grants Prevention and Public Health Fund 23
Incentives for Prevention of Chronic Disease in Medicaid The Participating States Nevada The Nevada Medicaid Incentives for Prevention of Chronic Diseases will give out points, redeemable for rewards, for participating in programs to control weight, lower cholesterol and blood pressure, and avoid the onset of diabetes. Medicaid and Nevada Check Up beneficiaries who are at risk of or diagnosed with diabetes will be rewarded for participating in diabetes self-management programs conducted by Nevada s Medicaid Managed Care Organizations, the University Medical Center or the YMCA. A third program, Healthy Hearts, will target 950 children at risk of heart disease in fee-for-service Medicaid. First Year Grant Award: $415,606 24
Challenges & Next Steps Translation of USPSTF recommendations to coverage benefits Gaps in coverage Gaps in cost-sharing requirements Protection of PPHF Transparency in health plans & government Tobacco surcharges & other wellness programs requiring behavior change Resources New Toolkit on Cessation FAQ: www.lung.org/acatoolkit Cessation Technical Assistance Project: www.lung.org/cessationta Other cessation resources: www.lung.org/cessationcoverage 25
Jennifer Singleterry Jennifer.Singleterry@lung.org 26
Tobacco Cessation as a Preventive Service: New Guidance Clarifies Affordable Care Act Provision The Patient Protection and Affordable Care Act (ACA) requires most health insurance plans to cover preventive services that have received an A or B grade recommendation from the U.S. Preventive Services Task Force (USPSTF). The ACA also requires these services be provided with no cost-sharing for the patient, which means no copays, coinsurance or deductibles. The USPSTF, an independent, volunteer panel of experts in prevention and evidence-based medicine, has given tobacco cessation interventions for adults an A grade. However, USPSTF recommendations are written as guidance for clinicians on what preventive services patients should receive, not as policy coverage language for insurance companies with complex coding and billing systems. As a result, it was unclear what cessation coverage was required to look like in practice: which tobacco cessation treatments should be included, what the frequency and duration of these treatments was supposed to be, and what limits insurers were allowed to place on these treatments. Even though many insurance plans have been required to cover tobacco cessation as a preventive service since 2010, a 2012 study by Georgetown University s Health Policy Institute found that only four of the cross section of 39 plans in six states analyzed in the study offered something approaching a comprehensive, evidence-based cessation benefit. Additionally, some of the 39 plans analyzed imposed cost-sharing requirements for the tobacco cessation treatments. Guidance for Health Plans On May 2, 2014, the U.S. Departments of Health and Human Services, Labor and Treasury issued guidance, in the form of an FAQ, on insurance coverage of tobacco cessation as a preventive service. i The guidance states that, to comply with ACA preventive services requirements, health plans should, for example, cover the following benefit: 1. Screening for tobacco use. 2. Two quit attempts per year, consisting of: Four sessions of telephone, individual and group cessation counseling lasting at least 10 minutes each per quit attempt; and, All medications approved by the FDA as safe and effective for smoking cessation, for 90 days per quit attempt, when prescribed by a health care provider. The guidance also reiterates that plans must not include cost-sharing for these treatments, and that plans should not require prior authorization for any of these treatments. Implementation in Health Plans The following health plans are required to cover tobacco cessation as a preventive service: Private group plans (large and small groups) that are not grandfathered ii Individual private plans that are not grandfathered Plans offered through State Health Insurance Marketplaces Alternative Benefit Plans (i.e., plans offered to the Medicaid expansion population where applicable) Fully implementing this guidance will make evidence-based tobacco cessation treatments available to millions of Americans, including many newly insured Americans, and would be expected to result in more tobacco users trying to quit and succeeding. i See Q5 in FAQ Part XIX: http://www.dol.gov/ebsa/faqs/faq-aca19.html ii For more information about grandfathered health plans: http://www.kaiserhealthnews.org/stories/2012/december/17/ grandfathered-plans-faq.aspx This factsheet was created for the Providing Technical Assistance for Effective Tobacco Cessation Policies project, funded by the Centers for Disease Control and Prevention. For more information, please visit www.lung.org/cessationta
Tobacco Cessation Coverage: What is Required? The Patient Protection and Affordable Care Act (ACA) was passed in March 2010, and many of its major provisions have been implemented over the last four years, culminating in new insurance coverage available to many Americans starting January 1, 2014. How did the ACA change requirements for what plans should be covering to help smokers quit in 2014? Insurance Type Who? Required coverage before ACA Required coverage now Medicare Age 65+ or some disabled individuals 4 sessions of individual counseling 4 prescription cessation medications Up to 2 quit attempts per year 4 sessions of individual counseling 4 prescription cessation medications Up to 2 quit attempts per year No cost-sharing Annual prevention visit Traditional Medicaid Low-income or disabled individuals, eligibility varies by state No federal requirements, coverage varied by state For Pregnant Women: Individual, group and phone counseling All tobacco cessation medications (prescription and OTC) No cost-sharing For all Medicaid Enrollees: All tobacco cessation medications (prescription and OTC) Coverage of counseling varies by state/plan Cost-sharing varies by state/plan Medicaid Expansion Low-income or disabled individuals, up to 138 percent of federal poverty level in states that expand Medicaid Not applicable Medicaid expansion did not exist prior to ACA Tobacco cessation treatment as a preventive service (see pg. 2) No cost-sharing At least 1 tobacco cessation medications Individual Insurance Plans* Individuals not buying insurance through an employer or part of a group, including through state health insurance marketplaces No tobacco cessation requirements Tobacco cessation treatment as a preventive service (see pg. 2) No cost-sharing 1-3 tobacco cessation medications, depending on the benchmark plan Small Group Plans* Individuals buying insurance through their small employer (100 or less full-time employees) or another small group, including through state health insurance marketplaces No tobacco cessation requirements Tobacco cessation treatment as a preventive service (see pg. 2) No cost-sharing 1-3 tobacco cessation medications, depending on the benchmark plan Employer- Provided Plans (Large Group/ Self-Insured)* Employees receiving insurance coverage through their employer No tobacco cessation requirements Tobacco cessation treatment as a preventive service (see pg. 2) No cost-sharing *Excluding plans that are grandfathered (those that were in operation before March 2010 and have not made significant changes) and do not have to meet ACA requirements. Cost-sharing: money a patient must pay when receiving treatment/filling a prescription copays, deductibles, coinsurance, etc. OTC Medication: medication you can buy over-the-counter without a prescription Benchmark plan: the plan each state has chosen to set the standard for other plans in the State Health Insurance Marketplace www.lung.org 1-800-LUNGUSA (1-800-586-4872) July 22, 2014
Tobacco Cessation Treatment as a Preventive Service The ACA requires many health insurance plans to cover all preventive services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF). Tobacco cessation for adults has an A rating from the USPSTF. However, the USPSTF rating and related recommendation was written for healthcare providers, not as a model for insurance coverage policy. As a result, there have been many questions since ACA implementation began in 2010 about what plans are required to cover for tobacco cessation. Evidence began to mount that most plans were not covering a true comprehensive cessation benefit. 1,2,3 The American Lung Association and other public health organizations repeatedly asked for clarification and guidance from the agencies implementing the ACA. 4 On May 2, 2014, the Departments of Health and Human Services, Labor and Treasury provided guidance on this topic. The departments issued a FAQ document, 5 translating the USPSTF recommendation into insurance coverage policy. The guidance stated that the Departments would consider the relevant health plans to be in compliance with the preventive service requirement for tobacco cessation if they cover, for example: Screening for tobacco use Individual, group or phone counseling (at least 10 minutes per session) All FDA-approved tobacco cessation medications (prescription and over-the-counter) when prescribed by a healthcare provider At least two quit attempts per year 4 sessions of counseling and 90 days of medication per quit attempt No prior authorization is required for treatment No cost-sharing is required 1. Georgetown University Health Policy Institute. Implementation of tobacco cessation coverage under the Affordable Care Act: Understanding how private health insurance policies cover tobacco cessation treatments. November 26, 2012. Available at: http://tfk.org/coveragereport/. 2. Centers for Disease Control and Prevention. Health Plan Implementation of U.S. Preventative Services Task Force A and B Recommendations Colorado, 2010. Morbidity and Mortality Weekly Report. October 7, 2011; 60(39):1348-50. 3. Kolade, FM. Tennessee Health Plan Tobacco Cessation Coverage. Public Health Nursing Journal. January-February 2014;31:28-35. 4. Most recently, see letter sent February 19, 2014: http://www.lung.org/get-involved/advocate/advocacydocuments/letter-sebelius-tobacco-cessation-benefit-02192014.pdf 5. United Sates Department of Labor. FAQs about Affordable Care Act Implementation (Part XIX). May 2, 2014. Available at: http://www.dol.gov/ebsa/faqs/faq-aca19.html. American Lung Association Helping Smokers Quit: Tobacco Cessation Coverage 2014