Transcript Implementation of the Affordable Care Act – Next Steps for Tobacco

Implementation of the Affordable
Care Act: Next Steps for
Tobacco Control
American Lung Association
Updated March 2013
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
Comprehensive Benefit
• 7 medications
– 5 NRTs
– Bupropion
– Varenicline
• 3 types of counseling
– Individual (face-to-face)
– Group
– Phone
• Easy to access/no limits
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
Federal Poverty Line = FPL
Persons in
family/household
FPL
200% of FPL
300% of FPL
400% of FPL
1
$11,170
22,340
33,510
44,680
2
15,130
30,260
45,390
60,520
3
19,090
38,180
57,270
76,360
4
23,050
46,100
69,150
92,200
Health Insurance Coverage in the U.S., 2011
Uninsured,
16%
Medicaid/Other
Public, 18%
Medicare,
13%
EmployerSponsored
Insurance,
49%
Total = 307.9 million
SOURCE: KCMU/Urban Institute analysis of the 2012 ASEC supplement to the CPS.
Private NonGroup, 5%
Health Insurance Coverage of the Nonelderly by
Poverty Level, 2010
Employer/Other Private
34%
29%
Medicaid/Other Public
15%
Uninsured
5%
4%
11%
30%
91%
46%
74%
41%
20%
<100% FPL
100-199% FPL
200-399% FPL
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.
400%+ FPL
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
2012 Developments
• June 2012: Supreme Court
Decision
– Upheld individual mandate
– Upheld Medicaid expansion
– Struck down enforcing mechanism for
Medicaid expansion
• November 2012: Obama reelected
– Means ACA is not likely to be
repealed
– Republicans will still try to dismantle
pieces
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
State Insurance Marketplaces
Now
Medicaid/
CHIP
Employer
Sponsored
Insurance
Uninsured
$-------------------------------------------------------------$$$
Income
State Insurance Marketplaces
2014
Medicaid/
CHIP
Marketplaces
Employer
Sponsored
Insurance
$-------------------------------------------------------------$$$
Income
Employer-Sponsored Insurance
• Grandfathered vs. Nongrandfathered
• Preventive Services
– Required to cover
USPSTF ‘A’ and ‘B’-rated
services
– Required to cover with no
copay
– Recommendation re:
tobacco cessation is
vague
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
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
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
Medicaid
• Joint federal & state program
• Four types of coverage
–
–
–
–
mandatory
states allowed to exclude
prohibited
not covered in the law
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
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
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”
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)
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
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
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)
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
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
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
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
2012
2013
2014
2015
2016
Source: http://healthreform.kff.org/en/the-states.aspx
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
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.
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
Prevention and Public Health Fund
Community Transformation
Grants
– Smokefree multi-unit housing
– Smokefree community
colleges
– Smokefree workplaces
– Reducing access to tobacco
products
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
Questions about this presentation?
[email protected]
202-785-3355