1. IMPLEMENTATION OF THE AFFORDABLE CARE ACT: NEXT STEPS FOR TOBACCO CONTROL The National Perspective Jennifer Singleterry Manager, National Health Policy American Lung Association Jennifer.singleterry@lung.org

2. Agenda 1.What should insurance plans cover? 2.What is covered for different types of insurance? 3.Next steps

3. Acronyms ACA = Affordable Care Act/healthcare reform/Obamacare HHS = Department of Health and Human Services EHB = Essential Health Benefit

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

5. Health Insurance Employer-sponsored insurance Medicare Medicaid Uninsured State exchanges Individual policies

6. Medicare ACA: new prevention and wellness visit Prescription medications provided through Part D –Missing: over-the-counter medications Individual counseling provided through Part B –Expanded in 2010 to include all on Medicare –Missing: group and phone counseling

7. 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 10 categories Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative services Laboratory services Preventive and wellness services Pediatric services

8. Essential Health Benefit Medicaid Expansion State Exchanges ?

9. Medicaid ACA: In 2014 will cover everyone up to 133% of the federal poverty line (approx. $31,000 annual income for family of 4) –Supreme Court decision Undergoing a lot of changes right now Has a higher smoking rate than the general population Joint federal & state program

10. Medicaid – Federal Requirements All preventive services for children through EPSDT ACA: tobacco cessation for pregnant women ACA, 2014: Medicaid expansion must have coverage for EHB ACA, 2014: States will no longer be able to exclude tobacco cessation medications. –Unclear what this means in practice

11. State Exchanges Begin in 2014 All plans in exchanges must cover EHB HHS has indicated implementation approach, but not published a rule Hot topic in the states!

12. State Exchanges – EHB 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 Plans in the exchange have a lot of flexibility

13. Employer-Sponsored Insurance ACA: Non-grandfathered plans must cover USPSTF A’s and B’s with no copay –Tobacco cessation is given an ‘A’, but is not clearly defined 9 states have tobacco cessation mandates –Only apply to fully-insured (ie small employers) –CO, IL, MD, NJ, NM, ND, OR, RI, VT

14. Uninsured 50 million currently (2010 - Kaiser) 30 million post-ACA (CBO estimate) Quitlines Other state and local programs Pharmacy & drug company discount programs

15. Prevention and Public Health Fund Quitline funding Tips from Former Smokers Campaign (Tips Part 2?) Community Transformation Grants In constant danger of being raided! –Cut by $6.25 billion in the Middle Class Tax Relief and Job Creation Act in 2012. –Stay tuned for more shenanigans

16. Next Steps Need to know: –Is your state setting up an exchange? –Has your state chosen an EHB benchmark? –Is your state carrying out the Medicaid expansion? –What are private plans in your state covering for tobacco cessation? Make contacts with Medicaid office, Insurance Commissioner, exchange implementers Reach out to health plans Reach out to patient navigator programs Advocate for better coverage!