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Implementation of the Affordable Care Act: Next Steps for Tobacco Control American Lung Association December 2012 Agenda 1. Health Insurance – today and the future 2. Affordable Care Act 1. Employer-sponsored Insurance 2. Medicaid 3. State Exchanges 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. – Gives letter grade recommendation to preventive services based on effectiveness – Tobacco cessation gets an ‘A’ 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Struck down enforcing mechanism for Medicaid expansion • November 2012: Obama reelected – Means ACA is not likely to be repealed – Republicans will still try to dismantle pieces State Exchanges Now Medicaid/ CHIP Employer Sponsored Insurance Uninsured $-------------------------------------------------------------$$$ Income State Exchanges 2014 Medicaid/ CHIP Exchanges Employer Sponsored Insurance $-------------------------------------------------------------$$$ 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 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 – Not indicated how they will implement. No regulations yet. • State implementation – ?? 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 medication – Mandatory – Allowed to exclude ? • Ongoing: transition to managed care 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 EHB benchmark plan that includes tobacco cessation State Exchanges • 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 Exchanges • Options for states: – Implement a full exchange on Jan. 1, 2014 – Implement part of an exchange in partnership with HHS until a full exchange can be implemented – Federal exchange operated in the state (“fall back” option) 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 Essential Health Benefits • December 16th Bulletin: http://cciio.cms.gov/resources/files/Fil es2/12162011/essential_health_bene fits_bulletin.pdf • FAQs: http://cciio.cms.gov/resources/files/Fil es2/02172012/ehb-faq-508.pdf • Proposed rule: http://www.gpo.gov/fdsys/pkg/FR2012-11-26/pdf/2012-28362.pdf Essential Health Benefits • 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 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 – substitutions within categories Good news: USPSTF A’s and B’s must be covered Essential Health Benefit • Benchmark can be 1 of 10 plans: – Three largest small group plans in the state – Three largest state employee health plans – Three largest Federal Employee Health Benefit Program plans – Largest HMO in the state • If a state does not choose in time, default is largest small group plan in the state Timeline • Benchmark plan to be confirmed by December 26, 2012 • 2013: determine which plans are in the exchange, 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? (Pre-benchmark) 1. Find out which 10 plans are benchmark options – http://cciio.cms.gov/resources/files/Files2/01272012/t op_three_plans_by_enrollment_508_20120125.pdf – Ask around 2. Eliminate options your state is unlikely to pick 3. Find out what each option covers for tobacco cessation 4. Consider publishing the results in report/factsheet/one-pager 5. Advocate for the best one! What Can You Do? (postbenchmark) • Find out what 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 exchange 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 (Tips Part 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