Tobacco Cessation Coverage From an insurance company perspective

Overview What is a comprehensive cessation benefit? What coverage is required? Next Steps This is what I am going to tell you today

What is a Comprehensive Cessation Benefit? Start with this, so we are all on the same page.

Comprehensive Benefit Cessation Coverage Comprehensive Benefit 7 Medications 5 NRTs (Gum, Patch, Lozenge, Nasal Spray, Inhaler) Bupropion Varenicline 3 Types of Counseling Individual (face-to-face) Group Phone Defined by: Treating Tobacco Use and Dependence: 2008 Update

Common Barriers to Access Care Cessation Coverage Common Barriers to Access Care Cost Sharing (Co-Pays) Prior Authorization Stepped Care Therapy Required Counseling Duration Limits Annual (or Lifetime) Limits Dollar Limits These are the common barriers.

Overview of key components: How the Affordable Care Act (ACA) expands tobacco cessation coverage

Increased Coverage Key ACA Components Pre- ACA 19.2 Million People – Have Health Coverage 2010 NHIS data shows Uninsured people smoke at a higher rate than those with private health insurance (32.4% vs 16.%) Medicaid expansion population smokes at a high rate, some states as high as 53% Uninsured Standard Medicaid Private Insurance Post – ACA Uninsured Standard Medicaid + Medicaid expansion The NHIS Numbers - page 89 (https://www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf) Key Points – ACA increased coverage (visual depiction is a vast exaggeration) also – only showing under 65. The newly covered group smokes at a higher rate, are less likely to be able to pay for cessation treatments on their own and are less likely to successfully overcome barriers to access Private Insurance + Exchange with Premium Subsidies

Tobacco Cessation and ACA Key ACA Components Tobacco Cessation and ACA Coverage Improvements Created more options for health coverage for those with pre-existing conditions Requires most plans to cover preventive services at no cost Created the Prevention and Public Health Fund Defined by: Treating Tobacco Use and Dependence: 2008 Update

Limits on Reach Key ACA Components June 2012 - United State Supreme Court struck down enforcement mechanism for Medicaid expansion, making it optional for states Implementation of the law has not been even across the country Trump Administration and Congress have repeatedly tried to repeal and weaken the law. Defined by: Treating Tobacco Use and Dependence: 2008 Update

(Affordable Care Act Requirements) What is Covered? (Affordable Care Act Requirements)

Standard Medicaid

Medicaid – Pregnant Women Cessation Coverage Medicaid – Pregnant Women 2010 ACA requirement All pregnant women on Medicaid have access to all treatments with no cost sharing. Written into the Law- ACA Section 4107 Includes all FDA-approved pharmacotherapy and counseling Smoking is linked to low birth weight and premature babies Secondhand smoke is linked to SIDS ACA Section 4107 Note: States needed to submit a state plan amendment

Standard Medicaid – Medications Requirement Cessation Coverage Standard Medicaid – Medications Requirement Section 2502 of the Affordable Care Act removed tobacco cessation medications from the exclusions list. Counseling not addressed. Many States are still not covering all 7 FDA-approved medications. Allows states to still charge a co-pay. .

Medicaid Expansion and Private Insurance

ACA Preventive Services Requirements Cessation Coverage ACA Preventive Services Requirements This Requirement Almost all private plans Plans sold in the exchanges Small group plans Individual plans Medicaid expansion plans Difference Requirements Medicare Standard Medicaid Plans Grandfathered Plans Sixty-three percent of covered workers are in a plan that is completely or partially self-funded In 2000 it was 49% National plans now offering self-insured products for groups as small as 50 employees Regulation varies – State Insurance comm 3rd party administration – ASO (Administrative Services Only)

Types of Health Coverage Essential Health Benefits ACA requires most plans to cover a minimum set of benefits: the Essential Health Benefits(EHB). The types of plans include: Private Plans, Exchange plans and Medicaid expansion plans. Includes the Preventive Services requirement.

ACA Preventive Service Requirement Cessation Coverage ACA Preventive Service Requirement ACA requires most private plans, including any plan sold on the exchange and Medicaid Expansion plans, to cover without cost-sharing all services given an ‘A’ or ‘B’ grade by United States Preventive Services Task Force (USPSTF). Tobacco Cessation receives an ‘A’ grade The ACA says all preventive services graded A or B by the USPSTF must be covered in most insurance products without any cost to the patient. I say most insurance products because some products are still grandfathered in and don’t have to comply with this component of the ACA. This requirement applies to Medicaid expansion and most private insurance. Tobacco cessation was rated A. It was initially unclear how this rating was to be translated into insurance coverage But there has now been two clarifications or updates to this initial rating…..

Key ACA Components – Cessation Coverage Cessation Guidance FAQ On May 2, 2014 the Departments of Labor, Treasury and Health and Human Services issues a FAQ questions on how the tobacco cessation recommendation should be implemented. Tobacco Cessation Guidance At least 4 sessions of individual, group and phone counseling At least 90 days of all FDA-approved smoking cessation medications, when prescribed At least 2 quit attempts per year No cost-sharing No prior authorization USPSTF is important, but it provides clinical recommendations, not policy. The FAQ is supposed to act like a bridge, translating the clinical recommendation into insurance policy. There are a few loopholes in the current FAQ that the insurance companies are unfortunately exploiting. Enforced by: State Health Insurance Commissioners, the Department of Labor and CMS 12 state Insurance Commissioners have taken action by either issuing a bulletin or consumer alert Ensures enforcement at state level, even if no enforcement at federal level The Lung Association along with our partners, including CWMN, sent a letter to the tri secretaries asking for a new FAQ removing the “for example” language, clarifying that plans need to provide all meds and counseling without cost sharing Q5

Key ACA Components - Cessation Coverage September 2015 USPSTF Updated Cessation Recommendation In September 2015, the USPSTF updated their recommendation, reaffirming the “A” grade for tobacco cessation. Found that both counseling and pharmacotherapy are effective to help smokers quit. States are responsible for implementation for private plans. In fall of 2015 the USPSTF updated the cessation interventions recommendation itself, clarifying that all types of counseling and all FDA-approved medications are included. Most health insurance products beginning after October 1, 2016 must comply with the updated rating. This updated rating, coupled with the FAQ, gives states, insurance companies and consumers a clear idea of what should be covered.

What does it mean? Cessation Coverage Studies have suggested that many private plans in the exchanges are not covering all cessation treatments and in some cases are imposing cost- sharing and other barriers. Information on coverage is often conflicting and confusing Some states are reaching out to large private employers to improve coverage. Some states have reached out to their Insurance Commissioner to ask for a bulletin or consumer alert clarifying what needs to be covered.

Questions? Anne DiGiulio, Anne.DiGiulio@Lung.org 202-785-3355