BILL ANALYSIS Ó
AB 1162
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Date of Hearing: April 21, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 1162
(Holden) - As Introduced February 27, 2015
SUBJECT: Medi-Cal: tobacco cessation.
SUMMARY: Requires tobacco cessation services to be a covered
benefit under the Medi-Cal program, as specified. Specifically,
this bill:
1)Defines a quit attempt as:
a) At least four tobacco cessation counseling sessions,
which may be conducted in-person or by phone, individually
or as a group; or,
b) A 90-day treatment regimen of any medication approved by
the federal Food and Drug Administration (FDA) for tobacco
cessation, including prescription and over-the-counter
medications.
2)Requires the Medi-Cal program to cover tobacco cessation
services, including unlimited quit attempts and no requirement
for a break between attempts for beneficiaries of any age.
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3)Exempts coverage of quit attempts from being subject to
requirements, including prior authorization, and requires only
a prescription from an authorized provider and proof of
Medi-Cal coverage as sufficient documentation to fill
prescriptions.
4)Prohibits a beneficiary from being required to receive a
specific service as a condition of receiving any other form of
treatment.
EXISTING LAW:
1)Establishes the Medi-Cal Program under the direction of the
Department of Health Care Services (DHCS), as California's
Medicaid program, to provide qualifying low-income individuals
health care and a uniform schedule of benefits.
2)Requires prior authorization for coverage of specified
Medi-Cal services.
3)Requires all preventive services that are assigned a grade of
A or B by the United States Preventive Services Task Force to
be provided without any cost sharing by Medi-Cal
beneficiaries, so the state can receive an increased federal
medical assistance percentage for these services.
FISCAL EFFECT: This bill has not yet been analyzed by a fiscal
committee.
COMMENTS:
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1)PURPOSE OF THIS BILL. According to the author, tobacco use is
the leading preventable cause of death in the U.S. and, though
the dangers of smoking are better understood now than fifty
years ago, smoking rates in the Medi-Cal population are still
too high. The author states the low success rate of quitting
is due to the fact that smokers often try quit without help,
which is typically ineffective. The author asserts that
FDA-approved tobacco cessation medications and counseling are
very effective methods of having smokers quit, yet maintains
that access to these services is sometimes difficult for
Medi-Cal recipients due to the many barriers to access
including requiring prior-authorization and step therapy. The
author concludes that these barriers, along with the inherent
difficulty of quitting, lead many to give up before they even
get started.
2)BACKGROUND.
a) Tobacco use in California and the United States. In
2011, the Centers for Disease Control and Prevention (CDC)
reported that California ranked second lowest in the
country in percentage of adults who currently smoke
cigarettes at 13.7%. Studies by the American Lung
Association have found that Medicaid enrollees have a
higher prevalence of smoking than the general population.
A separate study conducted in 2004 by CDC estimated that
approximately 45% of California's Medi-Cal population
smoked, and that total annual Medi-Cal expenditures
attributed to smoking were approximately 2.25 million
dollars.
b) Tobacco cessation treatments and coverage in the ACA.
Section 2502 of the Patient Protection and Affordable Care
Act (ACA) requires that smoking cessation drugs be removed
from the list of drugs that States may exclude from
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coverage in their Medicaid program, effective January 1,
2014. This section also explicitly prohibited State
Medicaid programs from excluding FDA-approved cessation
medications from coverage. The Centers for Medicare and
Medicaid Services issued guidance to states, specifying
that over-the-counter smoking cessation drugs are also no
longer excluded from coverage or otherwise restricted under
the Medicaid program.
Federal guidance in the ACA recommends the following coverage
for each cessation attempt: i) four tobacco cessation
counseling sessions of at least 10 minutes each (including
telephone counseling, group counseling, and individual
counseling) without prior authorization; and, ii) all
FDA-approved tobacco cessation medications (including both
prescription and over-the-counter medications) for a 90-day
treatment regimen when prescribed by a health care provider
without prior authorization.
c) Drugs Approved by the FDA. There are currently a
variety of FDA-approved over-the-counter nicotine
replacement products, including skin patches, lozenges and
chewing gum; these products are available under brand or
generic names to individuals over the age of 18. The only
prescription nicotine replacement product approved by the
FDA is Nicotrol. The FDA has also approved two products
for tobacco cessation that do not contain nicotine:
Chantix, a drug aimed at reducing cravings, and Zyban, an
anti-depressant focused on maintaining chemical balance as
a patient receives treatment.
d) DHCS Policy on Tobacco Cessation. On September 3, 2014,
DHCS released policy letter 14-006 to provide Medi-Cal
managed care health plans (MCPs) with minimum requirements
for comprehensive tobacco cessation services. The
requirements, similar to federal guidance on the issue, for
the following:
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i) Coverage of all seven FDA-approved tobacco cessation
medications, at least one of which must be available
without prior authorization - a cost-containment
procedure that requires a prescriber to obtain permission
to prescribe a medication prior to prescribing it - and
any additional tobacco cessation medications once
approved by the FDA;
ii) Coverage of a 90-day treatment regimen of
medications with other requirements, restrictions, or
barriers; and a minimum of two separate quit attempts per
year, with no mandatory break required between quit
attempts;
iii) MCPs may not require members to attend counseling
sessions or classes prior to receiving a prescription for
an FDA-approved tobacco cessation medication;
iv) MCPs must ensure that individual, group, and
telephone counseling is offered to members who wish to
quit smoking, whether or not those members opt to use
tobacco cessation medications; and,
v) Four counseling sessions of at least ten minutes
each in length for at least two separate quit attempts a
year without prior authorization.
The DHCS policy letter also specified requirements for
annual assessments, services for pregnant tobacco users,
provider training, and referral to the California Smokers'
Helpline.
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3)SUPPORT. The American Heart Association/American Stroke
Association, the American Lung Association, and the American
Cancer Society Cancer Action Network, the sponsors of this
bill, state that the success rate of smokers quitting their
addiction to tobacco is still very low, due in part because
many smokers try to quit without the assistance of tobacco
cessation services. The sponsors note that although the ACA
has made tobacco cessation treatments more accessible, current
guidelines as to how to implement these treatments are
unclear, thereby resulting in differences in coverage between
health plans. In addition, the sponsors state that Medi-Cal
patients face barriers to treatment services due to prior
authorization and step therapy treatment requirements. The
sponsors conclude that the bill provides clarity to both
Medi-Cal patients and plans on tobacco cessation coverage and
brings California in compliance with federal requirements
outlined in the expansion of the ACA.
Supporters of the bill argue smoking is the leading preventable
cause of death in the United States and patients who attempt
to quit smoking face barriers to cessation treatments.
Supporters state this bill provides needed clarity for
Medi-Cal participants on tobacco cessation services and
ensures access to comprehensive insurance coverage for these
services.
4)OPPOSITION. The California Association of Health Plans states
the bill will increase costs to the state by requiring
Medi-Cal managed care plans to pay for tobacco cessation drugs
in a manner that is inconsistent with policies of both DHCS
and sound medical management. The association also states
MCPs already comply with the requirements of the DHCS Policy
letter. Opposition also asserts that removing all prior
authorization protocols and requiring plans to cover all
specific medications would create a new benefit mandate, which
would result in higher state costs in Medi-Cal reimbursement
rates to plans in order to reflect the benefit expansion.
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5)PREVIOUS LEGISLATION.
a) SB 220 (Yee) of 2010 would have required a health care
service plan contract or health insurance policy issued,
amended, renewed or delivered after January 1, 2011, to
cover specified tobacco cessation treatments and requested
the California Health Benefits Review Program to prepare an
analysis of the cost savings as a result of the bill
provisions. This bill was vetoed by the Governor.
b) AB 2662 (Dymally) of 2007 would have provided that the
provision of one form of Medi-Cal covered tobacco cessation
services benefits, either pharmacotherapy or counseling,
shall not be a precondition to receive the other. This
bill was held in the Senate Appropriations Committee.
c) SB 576 (Ortiz) of 2005 would have required health plans
and health insurers to provide coverage for two courses of
tobacco cessation treatments per year, including counseling
and prescription and over-the-counter medications, and
prohibited plans and insurers from applying deductibles but
allowed specific co-payments for those benefits. This bill
was vetoed by the Governor.
6)POLICY CONSIDERATIONS. The bill implements coverage generally
in line with federal guidance for coverage of tobacco
cessation products, with the exception of the number of quit
attempts allowed by the bill go beyond federal guidelines.
This practice is not uncommon in California law as the
Legislature often views federal guidelines and law as a
minimum standard for state law.
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The Committee may wish to consider whether an unlimited number
of quit attempts is effective in helping beneficiaries quit
smoking in the long-term, or whether a limited number of quit
attempts, followed by an alternative treatment may be valuable
to beneficiaries who are particularly difficult to treat.
The Committee may also wish to define the minimum length of time
for each counseling session defined in the bill; as stated in
a previous section, the federal guidance recommends a minimum
of ten minutes per counseling session.
7)SUGGESTED TECHNICAL AMENDMENTS. The author has stated the
intent of the bill is to eliminate barriers to access for
tobacco cessation services, including step therapy. The bill
language, as currently written, is unclear. The committee
suggests the following amendment:
Strike subdivision c of Section 14134.25 and insert:
(c) Beneficiaries covered under this section shall not be
required to receive a particular form of tobacco
cessation service as a condition of receiving any other
form of tobacco cessation service.
REGISTERED SUPPORT / OPPOSITION:
Support
American Cancer Society Cancer Action Network (cosponsor)
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American Heart Association/American Stroke Association
(cosponsor)
American Lung Association in California (cosponsor)
Biocom
California Academy of Family Physicians
California American College of Emergency Physicians
California Black Health Network
California Healthcare Institute
California Medical Association
California Pan-Ethnic Health Network
California Primary Care Association
Western Center on Law and Poverty
Opposition
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California Association of Health Plans
Analysis Prepared by:An-Chi Tsou / HEALTH / (916) 319-2097