Transcript Welcome (title here) - Wellness Council of Northeast Ohio

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-thecounter 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: http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/index.html#Clinic.
http://www.dol.gov/ebsa/faqs/faq-aca19.html
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 overthe-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-aNurse” 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: 614-644-8286, [email protected].

You may also report issues with non-compliance to the Ohio Department of
Insurance Consumer Hotline: 1-800-686-1526 or
http://www.insurance.ohio.gov/aboutodi/ODIDiv/Pages/ContactConsumer.aspx

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
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
Program Costs:
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
http://ohio.QuitLogix.org
• eCoach text and emails:
• Texts: trigger based, Texts-for-Help
• Emails: motivational, quit anniversary, reengagement
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 43215
614-644-8286
[email protected]