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Implementation of the Affordable Care Act: Next Steps for Tobacco Control American Lung Association December 2012. Agenda. Health Insurance – today and the future Affordable Care Act Employer-sponsored Insurance Medicaid State Exchanges Prevention & Public Health Fund What you can do.

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Implementation of the Affordable Care Act: Next Steps for Tobacco ControlAmerican Lung AssociationDecember 2012
  • Health Insurance – today and the future
  • Affordable Care Act
    • Employer-sponsored Insurance
    • Medicaid
    • State Exchanges
    • Prevention & Public Health Fund
  • What you can do
comprehensive benefit
Comprehensive Benefit
  • 7 medications
    • 5 NRTs
    • Bupropion
    • Varenicline
  • 3 types of counseling
    • Individual (face-to-face)
    • Group
    • Phone
  • Easy to access/no limits
  • 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’
health insurance coverage in the u s 2011
Health Insurance Coverage in the U.S., 2011

SOURCE: KCMU/Urban Institute analysis of the 2012 ASEC supplement to the CPS.

Uninsured, 16%

Medicaid/Other Public, 18%

Medicare, 13%

Employer-Sponsored Insurance, 49%

Private Non-Group, 5%

Total = 307.9 million

health insurance coverage of the nonelderly by poverty level 2010
Health Insurance Coverage of the Nonelderly by Poverty Level, 2010

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.

affordable care act
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
2012 Developments
  • June 2012: Supreme Court Decision
    • Upheld individual mandate
    • Upheld Medicaid expansion
    • Struck down enforcing mechanism for Medicaid expansion
  • November 2012: Obama re-elected
    • Means ACA is not likely to be repealed
    • Republicans will still try to dismantle pieces
state exchanges


State Exchanges

Employer Sponsored Insurance





state exchanges1


State Exchanges

Employer Sponsored Insurance





employer sponsored insurance
Employer-Sponsored Insurance
  • Grandfathered vs. Non-grandfathered
  • 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
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

  • 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
    • ??
  • Joint federal & state program
  • Four types of coverage
    • mandatory
    • states allowed to exclude
    • prohibited
    • not covered in the law
  • 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


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 do1
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 exchanges2
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 exchanges3
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
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
Essential Health Benefits

December 16th Bulletin:


Proposed rule:

essential health benefits1
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 benefits2
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 benefit1
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


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

what can you do pre benchmark
What Can You Do? (Pre-benchmark)
  • Find out which 10 plans are benchmark options
    • Ask around
  • Eliminate options your state is unlikely to pick
  • Find out what each option covers for tobacco cessation
  • Consider publishing the results in report/factsheet/one-pager
  • Advocate for the best one!
what can you do post benchmark
What Can You Do? (post-benchmark)
  • 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
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 fund1
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 fund2
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 do2
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 jennifer singleterry@lung org 202 785 3355
Questions about this presentation?Jennifer.Singleterry@Lung.org202-785-3355