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Tobacco Cessation Coverage

This article provides an overview of tobacco cessation coverage, including the requirement for comprehensive benefits, common barriers to accessing care, and how the Affordable Care Act (ACA) has expanded coverage. It also highlights the specific coverage requirements for Medicaid, private insurance, and preventive services under the ACA.

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Tobacco Cessation Coverage

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  1. Tobacco Cessation Coverage

  2. Overview • What is a comprehensive cessation benefit? • What coverage is required? • Next Steps

  3. What is a Comprehensive Cessation Benefit?

  4. Cessation Coverage Comprehensive Benefit • 7 Medications • 5 NRTs (Gum, Patch, Lozenge, Nasal Spray, Inhaler) • Bupropion • Varenicline • 3 Types of Counseling • Individual (face-to-face) • Group • Phone

  5. Cessation Coverage Common Barriers to Access Care • Cost Sharing (Co-Pays) • Prior Authorization • Stepped Care Therapy • Required Counseling • Duration Limits • Annual (or Lifetime) Limits • Dollar Limits

  6. Overview of key components: How the Affordable Care Act (ACA) expands tobacco cessation coverage

  7. Key ACA Components Increased Coverage Pre- ACA Uninsured • 19.2 Million People – Have Health Coverage • 2010 NHIS data shows Uninsured people smoke at a higher rate than those with private health insurance (32.4% vs 16.%) • Medicaid expansion population smokes at a high rate, some states as high as 53% Standard Medicaid Private Insurance Post – ACA Uninsured Standard Medicaid + Medicaid expansion Private Insurance + Exchange with Premium Subsidies

  8. Key ACA Components Tobacco Cessation and ACA Coverage Improvements • Created more options for health coverage for those with pre-existing conditions • Requires most plans to cover preventive services at no cost • Created the Prevention and Public Health Fund

  9. Key ACA Components Limits on Reach • June 2012 - United State Supreme Court struck down enforcement mechanism for Medicaid expansion, making it optional for states • Implementation of the law has not been even across the country • Trump Administration and Congress have repeatedly tried to repeal and weaken the law.

  10. What is Covered? (Affordable Care Act Requirements)

  11. Standard Medicaid

  12. Cessation Coverage Medicaid – Pregnant Women • 2010 ACA requirement • All pregnant women on Medicaid have access to all treatments with no cost sharing. • Written into the Law- ACA Section 4107 • Includes all FDA-approved pharmacotherapy and counseling

  13. Cessation Coverage Standard Medicaid – Medications Requirement • Section 2502 of the Affordable Care Act removed tobacco cessation medications from the exclusions list. • Counseling not addressed. • Many States are still not covering all 7 FDA-approved medications. • Allows states to still charge a co-pay.

  14. Medicaid Expansion and Private Insurance

  15. Cessation Coverage ACA Preventive Services Requirements This Requirement • Almost all private plans • Plans sold in the exchanges • Small group plans • Individual plans • Medicaid expansion plans Difference Requirements • Medicare • Standard Medicaid Plans • Grandfathered Plans

  16. Types of Health Coverage Essential Health Benefits • ACA requires most plans to cover a minimum set of benefits: the Essential Health Benefits(EHB). The types of plans include: Private Plans, Exchange plans and Medicaid expansion plans. • Includes the Preventive Services requirement.

  17. Cessation Coverage ACA Preventive Service Requirement • ACA requires most private plans, including any plan sold on the exchange and Medicaid Expansion plans, to cover without cost-sharing all services given an ‘A’ or ‘B’ grade by United States Preventive Services Task Force (USPSTF). • Tobacco Cessation receives an ‘A’ grade

  18. Key ACA Components – Cessation Coverage Cessation Guidance FAQ • On May 2, 2014 the Departments of Labor, Treasury and Health and Human Services issues a FAQ questions on how the tobacco cessation recommendation should be implemented. • Tobacco Cessation Guidance • At least 4 sessions of individual, group and phone counseling • At least 90 days of all FDA-approved smoking cessation medications, when prescribed • At least 2 quit attempts per year • No cost-sharing • No prior authorization Q5

  19. Key ACA Components - Cessation Coverage September 2015 USPSTF Updated Cessation Recommendation • In September 2015, the USPSTF updated their recommendation, reaffirming the “A” grade for tobacco cessation. • Found that both counseling and pharmacotherapy are effective to help smokers quit. • States are responsible for implementation for private plans.

  20. Cessation Coverage What does it mean? • Studies have suggested that many private plans in the exchanges are not covering all cessation treatments and in some cases are imposing cost-sharing and other barriers. • Information on coverage is often conflicting and confusing • Some states are reaching out to large private employers to improve coverage. • Some states have reached out to their Insurance Commissioner to ask for a bulletin or consumer alert clarifying what needs to be covered.

  21. Questions? Anne DiGiulio, Anne.DiGiulio@Lung.org 202-785-3355

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