IMPLEMENTATION OF THE AFFORDABLE CARE ACT: NEXT STEPS FOR TOBACCO CONTROL

The National Perspective

Jennifer SingleterryManager, National Health Policy

American Lung AssociationJennifer.singleterry@lung.org

Agenda

1.What should insurance plans cover?

2.What is covered for different types of insurance?

3.Next steps

Acronyms

• ACA = Affordable Care Act/healthcare reform/Obamacare

• HHS = Department of Health and Human Services

• EHB = Essential Health Benefit

Comprehensive Benefit

• 7 medications– 5 NRTs– Bupropion– Varenicline

• 3 types of counseling– Individual (face-to-face)– Group– Phone

• Easy to access/no limits

Health Insurance

• Employer-sponsored insurance

• Medicare• Medicaid• Uninsured• State exchanges• Individual policies

Medicare

• ACA: new prevention and wellness visit

• Prescription medications provided through Part D– Missing: over-the-counter medications

• Individual counseling provided through Part B– Expanded in 2010 to include all on

Medicare– Missing: group and phone counseling

Essential Health Benefit

ACA: directs HHS Secretary to establish an Essential Health Benefit – a minimum federal standard

– Must include 10 categories of coverage

– Applies to all plans in state exchanges

– Applies to coverage offered to newly eligible Medicaid enrollees

10 categoriesAmbulatory patient servicesEmergency servicesHospitalizationMaternity and newborn careMental health and substance use disorder servicesPrescription drugsRehabilitative servicesLaboratory servicesPreventive and wellness servicesPediatric services

Essential Health Benefit

Medicaid Expansion

State Exchanges

?

Medicaid

• ACA: In 2014 will cover everyone up to 133% of the federal poverty line (approx. $31,000 annual income for family of 4)– Supreme Court decision

• Undergoing a lot of changes right now

• Has a higher smoking rate than the general population

• Joint federal & state program

Medicaid – Federal Requirements

• All preventive services for children through EPSDT

• ACA: tobacco cessation for pregnant women• ACA, 2014: Medicaid expansion must have

coverage for EHB• ACA, 2014: States will no longer be able to

exclude tobacco cessation medications.– Unclear what this means in practice

State Exchanges

• Begin in 2014• All plans in exchanges must

cover EHB• HHS has indicated

implementation approach, but not published a rule

• Hot topic in the states!

State Exchanges – EHB

• Each state picks its own benchmark plan• Benchmark plan’s coverage serves as the

Essential Health Benefit (a minimum state standard)

• Must supplement if benchmark does not cover all 10 categories of care

• Plans in the exchange have a lot of flexibility

Employer-Sponsored Insurance

• ACA: Non-grandfathered plans must cover USPSTF A’s and B’s with no copay– Tobacco cessation is given an ‘A’,

but is not clearly defined

• 9 states have tobacco cessation mandates– Only apply to fully-insured (ie small

employers)– CO, IL, MD, NJ, NM, ND, OR, RI,

VT

Uninsured

• 50 million currently (2010 - Kaiser)• 30 million post-ACA (CBO estimate)• Quitlines• Other state and local programs• Pharmacy & drug company discount programs

Prevention and Public Health Fund

• Quitline funding• Tips from Former Smokers

Campaign (Tips Part 2?)• Community Transformation Grants• In constant danger of being

raided!– Cut by $6.25 billion in the Middle

Class Tax Relief and Job Creation Act in 2012.

– Stay tuned for more shenanigans

Next Steps• Need to know:

– Is your state setting up an exchange?– Has your state chosen an EHB benchmark? – Is your state carrying out the Medicaid expansion?– What are private plans in your state covering for

tobacco cessation?

• Make contacts with Medicaid office, Insurance Commissioner, exchange implementers

• Reach out to health plans • Reach out to patient navigator programs• Advocate for better coverage!