Moving Toward ACA Compliance in Ohio: Tobacco Cessation Benefits Presented to the Wellness Council of Northeast Ohio October 23, 2014

Providing an ACA-Compliant Tobacco Cessation Benefit Ohio Department of Health Tobacco Program The Affordable Care Act and its May 2014 FAQ Ohio Tobacco Collaborative: ROI Benefits Reports

Ohio Department of Health Tobacco Use Prevention and Cessation Program priorities: Promote quitting tobacco products Prevent youth tobacco use Eliminate exposure to environmental tobacco smoke

Patient Protection Affordable Care Act Effective 9/23/2010, non-grandfathered plans must include all United States Preventive Services Task Force (USPSTF) A and B recommendations Tobacco cessation is an “A” recommendation No member cost sharing permitted

May 2014 FAQ Q5: The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. What are plans and issuers expected to provide as preventive coverage for tobacco cessation interventions? Plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for a recommended preventive service, to the extent not specified in the recommendation or guideline regarding that preventive service. Evidence-based clinical practice guidelines can provide useful guidance for plans and issuers. The Departments will consider a group health plan or health insurance issuer to be in compliance with the requirement to cover tobacco use counseling and interventions, if, for example, the plan or issuer covers without cost-sharing: 1.Screening for tobacco use; and, 2.For those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for: – Four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling and individual counseling) without prior authorization; and – All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the- counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. This guidance is based on the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update, available at: recommendations/tobacco/index.html#Clinic. recommendations/tobacco/index.html#Clinic

Why is the FAQ so important? For the first time since the ACA was passed, it provides clarification on what should be provided as a compliant tobacco cessation benefit. USPSTF recommendations are not written in benefit design terms so until the FAQ there was a great deal of ambiguity. For example: USPSTF says more cessation attempts is better, but does not indicate how many.

Who is responsible? Fully-Insured (does not apply to grandfathered plans)  The health plan is responsible for selling fully insured products that meet the requirements of the ACA.  This means that ACA-compliant tobacco cessation services should be included as part of the health plan’s baseline coverage.  If a health plan outsources an ACA-required component of care, the health plan includes those components in its rate filings to the state insurance regulators and is accountable for managing the service. Typically done with mental health and pharmacy.  Insured employers do not typically have the option to “carve out” a required benefit.  Implication of this is that a rider or buy-up option is not compliant. Self-Insured (does not apply to grandfathered plans)  Although the employer is responsible for providing ACA-compliant benefit plans, they typically rely on either their agent consultant or their third party administrator (TPA) for guidance.  The presence of three entities that could be responsible for this benefit appears to have caused a situation in which no one takes ownership.  Appears this issue is often not even on the radar.

Benefit requirements: pharm & screening  Pharmacotherapy  Typically part of the health plan’s formulary and is specific to prescription-based medications (some plans offer coverage of over- the-counter drugs but many do not).  Most significant change would be removing the copays or coinsurance for the over the counter and prescription medications  Screening  Generally considered the responsibility of the providers  Reimbursement for screening is rare and there is no unique billing code for claims submission.

Benefit requirements: counseling  Counseling includes individual, group, and telephonic.  Individual: There are counseling codes that permit reimbursement based on the amount of time a provider expends counseling a patient to quit tobacco use. These codes are not used extensively by providers – in part due to lack of awareness and in part due to complexity of when they can be included (e.g. as part of a standard office visit that covers other issues).  Generally offered as part of an overall wellness program or “Ask-a- Nurse” options (by non-physicians)  Group: Not typically available  Telephonic: May be part of an “Ask-a-Nurse” option or a coaching option

Benefit requirements (continued)  Tobacco cessation counseling is typically not part of a health plan’s core benefit package  Group model health plans are the most likely to incorporate wellness and counseling in their core benefit designs (e.g. Medical Mutual).  Most commercial health plans house the component parts of a cessation benefit in multiple places  Results in fragmentation and no one single entity responsible for ensuring all components are compliant  Changing a benefit requires significant lead time and filing with the insurance regulators

Compliance & Action Steps  All health plans and self-insured employers must offer a tobacco cessation benefit with no member cost-sharing, that includes:  Pharmacotherapy  Counseling  At least two quit attempts per year  The evidence indicates that many health plans and employers are not in compliance  If you are not sure that the benefit you offer, or the benefit you receive, is in compliance, contact: Laura Friedenberg, Tobacco Program Administrator, Ohio Department of Health: ,  You may also report issues with non-compliance to the Ohio Department of Insurance Consumer Hotline: or  Please let ODH (Laura) know when you report to ODI so we can track issues

Ohio Tobacco Collaborative Public-private partnership  Leverages the buying power of employers, health plans, the Ohio Tobacco Quit Line and the ODH  Works with National Jewish Health, vendor for the Ohio Tobacco Quit Line  Health plans and employers can provide nicotine replacement therapy (NRT) at cost and greatly discounted telephonic counseling services  Counseling  $138 for up to five proactive telephonic coaching sessions (English or Spanish)  NRT mailed to the individual’s home  $36 for a two-week supply  $54 for a four-week supply

Return on Investment Impact on Employers’ Bottom Line  An evidence-based benefit can provide an ROI for an employer  In the first year based on productivity gains  In the second year based on medical savings  A poorly structured benefit will add cost without generating any measurable benefit.

Return on investment Return on Investment Program Costs:200 x $138 = $27,600 NRT Costs:200 x $54 = $10,800 Quit Rates:33% x 200 = 66 Cost of a Smoker:$2,132 Medical Cost Savings:66 x $2,132 = $140,712 Savings – Cost:$140,712 - $27,600 - $10,800 = $102,312 ROI = 2.7

Ohio Tobacco Quit Line Eligibility  Only Medicaid fee-for-service clients, uninsured and pregnant women receive free cessation services from the Ohio Quit Line  All other callers may continue to access Quit Line services free of charge only if their health plan or employer joins the Ohio Tobacco Collaborative (OTC)  Funding restrictions Three year average quit rate  > 33% Foundation for ACA compliance  Plans need to offer individual and group counseling, and prescription benefit

1-800-QUIT-NOW Allows public health and others to recommend that physicians use the 5 As for all patients Ask Advise Assess Assist Arrange If all Ohio health plans joined the Ohio Tobacco Collaborative – Easy message to physicians – Doesn’t require physicians to know specifics of patients’ health plan to take action

Quit Line script “Under the new health reform law, most health insurance plans provide help to stop using tobacco at no cost. Your employer or health insurance plan has chosen not to use the Ohio Tobacco Quit Line but may have other options to assist you. Please call your human resource department or the number on the back of your insurance ID card.”

National Jewish Health Enrolls hundreds of individuals/day from all over the country. Has helped over 960,000 participants with their quit attempt.

Ohio Tobacco Collaborative: phone Coaching calls Personalized coaching (5 outgoing calls) ~15 minutes English and Spanish speaking coaches Unlimited incoming calls

Ohio Tobacco Collaborative: online Access to online tobacco cessation tools via eCoach text and s: Texts: trigger based, Texts-for-Help s: motivational, quit anniversary, re- engagement

Ohio Tobacco Collaborative: NRT Nicotine Replacement Therapy Delivers nicotine without toxins from tobacco 4 weeks of patches, gum, or lozenges Certain medical conditions may require medical consent (doctor’s approval)

Ohio Tobacco Collaborative: reports Comprehensive reports are available to help you determine how your company’s health care costs are affected as a result of an employee’s reduction or cessation of tobacco. Standard monthly reports include: Monthly activity report Monthly enrollment/completion report Annual report

For more info, questions, or to enroll: Laura Friedenberg, MA Tobacco Program Administrator Ohio Department of Health 246 North High St. Columbus, OH