1. Implementation of the Affordable Care Act: Next Steps for Tobacco Control American Lung Association Updated March 2013

2. Agenda 1.Health Insurance – today and the future 2.Affordable Care Act 1.Employer-sponsored Insurance 2.Medicaid 3.State Insurance Marketplaces 4.Prevention & Public Health Fund 3.What you can do

3. Comprehensive Benefit 7 medications –5 NRTs –Bupropion –Varenicline 3 types of counseling –Individual (face-to-face) –Group –Phone Easy to access/no limits

4. 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 ABP = Alternative Benefit Plan

5. Federal Poverty Line = FPL Persons in family/householdFPL200% of FPL300% of FPL400% of FPL 1$11,17022,34033,51044,680 215,13030,26045,39060,520 319,09038,18057,27076,360 423,05046,10069,15092,200

6. Health Insurance Coverage in the U.S., 2011 SOURCE: KCMU/Urban Institute analysis of the 2012 ASEC supplement to the CPS. Total = 307.9 million Employer- Sponsored Insurance, 49% Medicaid/Other Public, 18% Medicare, 13% Private Non- Group, 5% Uninsured, 16%

7. Health Insurance Coverage of the Nonelderly by Poverty Level, 2010 FPL= Federal Poverty Level. The FPL was $22,050 for a family of four in 2010. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.

8. Affordable Care Act Already accomplished: –Closing of Medicare “donut hole” –More options for people with pre-existing conditions –Extended coverage for young adults –Required all private health plans to cover preventive care at no cost –Tobacco cessation coverage for pregnant women on Medicaid –Prevention and Public Health Fund

9. 2012 Developments June 2012: Supreme Court Decision –Upheld individual mandate –Upheld Medicaid expansion –Struck down enforcing mechanism for Medicaid expansion November 2012: Obama re- elected –Means ACA is not likely to be repealed –Republicans will still try to dismantle pieces

10. 2013 Developments HHS has begun implementing 2014 changes by releasing several proposed and final rules. –Essential Health Benefit in state insurance marketplaces –Essential Health Benefit in Medicaid expansion –Insurance ratings (including ratings based on tobacco use) –Wellness programs

11. State Insurance Marketplaces Uninsured $-------------------------------------------------------------$$$ Income Medicaid/ CHIP Employer Sponsored Insurance Now

12. State Insurance Marketplaces $-------------------------------------------------------------$$$ Income Medicaid/ CHIP Employer Sponsored Insurance 2014 Marketplaces

13. Employer-Sponsored Insurance Grandfathered vs. Non- grandfathered Preventive Services –Required to cover USPSTF ‘A’ and ‘B’-rated services –Required to cover with no copay –Recommendation re: tobacco cessation is vague

14. Employer-Sponsored Insurance Study released in November 2012 showed that private plans were not covering tobacco cessation treatments in a uniform way. 4 out of 39 plans analyzed covered even close to a comprehensive benefit Some plans included cost-sharing, which is prohibited by ACA

15. What Can You Do? Encourage private insurance companies to interpret the USPSTF requirement comprehensively Integrate quitline and other cessation services with health plans Submit comments to HHS if the opportunity arises

16. Medicaid Supreme Court –HHS Secretary cannot threaten to take away all federal Medicaid funds if a state does not expand Medicaid up to 138% FPL HHS –Emphasizing flexibility so that as many states as possible will implement the expansion State implementation –?? Decisions are ongoing

18. Medicaid Joint federal & state program Four types of coverage –mandatory –states allowed to exclude –prohibited –not covered in the law

19. Medicaid Comprehensive Tobacco Cessation Benefit for pregnant women –October 1, 2010 –June 2011 letter to State Medicaid Directors Rest of people on Medicaid –Still up to the states

21. Medicaid Future changes: 2013: Incentive to cover preventive services 2014: Essential Health Benefit for new enrollees 2014: Tobacco cessation medications are no longer excludable Ongoing: transition to managed care

22. EHB in Medicaid Expansion HHS released a proposed rule in January 2013 Alternative Benefit Plans (ABPs) = Plans covering Medicaid expansion population ABPs must cover tobacco cessation as a preventive service –States are allowed to charge cost-sharing Must cover tobacco cessation medications, but have wide latitude in “utilization management techniques”

23. Tobacco Cessation Medications States will no longer be able to exclude coverage of tobacco cessation medications in 2014 Will this mean the drugs are truly accessible? –Add to preferred drug lists –Remove barriers (utilization management techniques)

24. What Can You Do? Find out details of your state’s Medicaid coverage (utilization) Connect Health Department with Medicaid Department Advocate for better coverage Share successes Crunch numbers Keep track of your state’s progress toward 2014 Medicaid expansion Advocate for the expansion (if necessary) Advocate for an ABP that covers a comprehensive cessation benefit

25. State Insurance Marketplaces To be implemented Jan. 1, 2014 States must decide: –Who has authority? –Governing structure? –Clearing house or active purchaser? –Consumer pieces Website Patient navigators –Integration with Medicaid, CHIP, etc. –Essential Health Benefit benchmark plan

26. State Insurance Marketplaces Three kinds of states: –Implementing a full marketplace on Jan. 1, 2014 –Implementing part of a marketplace in partnership with HHS until a full marketplace can be implemented –Federally facilitated exchange (no state involvement)

27. Essential Health Benefit in Marketplaces 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 marketplaces –Applies to coverage offered to newly eligible Medicaid enrollees

28. Essential Health Benefit in Marketplaces Each state has picked its own benchmark plan (or defaulted to a 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

29. Essential Health Benefits Bad news: A LOT of flexibility is allowed for individual plans. “Substantially equal” Specific services covered Quantitative limits Substitutions within categories Medications – plan must cover as many drugs in a category as the benchmark does Good news: USPSTF A’s and B’s must be covered

30. Timeline Benchmark plan confirmed December 26, 2012 2013: determine which plans are in the marketplace, set up technical & consumer aspects Jan. 1, 2014: start date 2016: re-evaluation 20122013201420152016

31. Source: http://healthreform.kff.org/en/the-states.aspx

32. What Can You Do? Find out what your state’s benchmark plan covers for tobacco cessation Make contacts in Insurance Commissioner’s office – how flexible will they be with potential plans? Will they allow substitutions? Outreach to potential state marketplace plans Outreach to patient navigator program

33. 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 In constant danger of being raided Cut by $6.25 billion in the Middle Class Tax Relief and Job Creation Act in 2012.

34. Prevention and Public Health Fund Quitline funding Tips from Former Smokers Campaign (Parts 1 & 2) Community Transformation Grants –support intensive approaches to reduce risk factors responsible for the leading causes of death and disability –prevent and control chronic diseases –Tobacco is a major focus –Also focused on health disparities, including SES

35. Prevention and Public Health Fund Community Transformation Grants –Smokefree multi-unit housing –Smokefree community colleges –Smokefree workplaces –Reducing access to tobacco products

36. What Can You Do? Find out quitline numbers Promote success stories Share “Tips” ads & materials Reach out to the media Find CTG projects in your state Crunch numbers Find out how your Members of Congress voted Advocate for protecting the Prevention Fund

37. Questions about this presentation? Jennifer.Singleterry@Lung.org 202-785-3355 Jennifer.Singleterry@Lung.org