BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 1162|
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THIRD READING
Bill No: AB 1162
Author: Holden (D)
Amended: 8/31/15 in Senate
Vote: 21
SENATE HEALTH COMMITTEE: 8-0, 7/8/15
AYES: Hernandez, Nguyen, Hall, Monning, Nielsen, Pan, Roth,
Wolk
NO VOTE RECORDED: Mitchell
SENATE APPROPRIATIONS COMMITTEE: 6-1, 8/27/15
AYES: Lara, Beall, Hill, Leyva, Mendoza, Nielsen
NOES: Bates
ASSEMBLY FLOOR: 67-12, 6/3/15 - See last page for vote
SUBJECT: Medi-Cal: tobacco cessation
SOURCE: American Cancer Society Cancer Action Network
American Heart Association/American Stroke Association
American Lung Association in California
DIGEST: This bill requires tobacco cessation services to be a
covered benefit under the Medi-Cal program, and requires tobacco
cessation services to include all intervention recommendations,
as periodically updated, assigned a grade A or B by the United
States Preventive Services Task Force (USPSTF).
ANALYSIS:
Existing law:
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1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which basic
health care services are provided to qualified low-income
persons.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes the purchase of prescribed drugs, subject to
the Medi-Cal List of Contract Drugs and utilization controls.
3)Requires that preventive services assigned a grade of A or B
by the U.S. Preventive Services Task Force be provided to
Medi-Cal beneficiaries without any cost sharing by the
beneficiary in order for the state to receive increased
federal contributions for those services, as specified.
This bill:
1)Requires tobacco cessation services to be covered benefits
under the Medi-Cal program, subject to utilization controls.
2)Requires tobacco cessation services to include all
intervention recommendations, as periodically updated, that
are assigned a grade A or B by the USPSTF.
3)Requires, in addition to 2) above, tobacco cessation services
to include a minimum of four quit attempts per year, with no
required break between attempts, for all beneficiaries 18 year
of age and older who use tobacco.
4)Requires, for beneficiaries under 18 years of age, tobacco
cessation services to be provided in accordance with the
American Academy of Pediatrics guidelines and the intervention
recommendations, as periodically updated, assigned a grade A
or B by the USPSTF.
5)Requires, in addition to the services described above, and
only to the extent consistent with the intervention
recommendations, as periodically updated, assigned a grade A
or B by the USPSTF, tobacco cessation services to include:
a) At least four tobacco cessation counseling sessions per
quit attempt, which may be conducted in person or by
telephone and individually or as part of a group, at the
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beneficiary's option.
b) A 12-week treatment regimen of any medication approved
by the federal Food and Drug Administration (FDA) for
tobacco cessation, including prescription and
over-the-counter medications.
6)Requires at least one prescription medication and all
over-the-counter medications (OTC) to be available without
prior authorization.
7)Requires a prescription from a provider with authority to
prescribe and proof of Medi-Cal coverage to be sufficient
documentation to fill a prescription for OTC tobacco cessation
medications.
8)Requires DHCS, effective January 1, 2016, to seek any federal
approvals necessary to implement this bill that DHCS
determines are necessary to implement its provisions.
9)Requires this bill to be implemented only to the extent that
federal financial participation is available, and any
necessary federal approvals have been obtained.
Comments
1)Author's statement. According to the author, quitting tobacco
products is a difficult feat that many attempt every year but
few accomplish. It can cause cancer, respiratory and heart
diseases, birth defects and is still the leading preventable
cause of death in the United States. Though the dangers of
smoking are better understood now than 50 years ago,
cigarettes are more addictive than ever and smoking rates in
the Medi-Cal population are still too high. In addition to
efforts to discourage people from smoking, this bill fights
against tobacco dependence by giving smokers the tools to
fight the addiction. The coverage mandated by this bill
ensures that Medi-Cal patients have access to clinically
proven treatments like counseling, medication, and nicotine
replacement treatments. Studies have shown that the
comprehensive coverage of these treatments has led to
decreases in the smoking population. Tobacco companies make it
hard enough for smokers to quit, as a state we must remove all
barriers to treatments that make quitting possible.
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2)Background on tobacco. According to the Centers for Disease
Control and Prevention, tobacco use is the leading preventable
cause of death in the United States. Every year, smoking kills
480,000 Americans and costs the nation at least $130 billion
in medical care costs for adults and more than $150 billion in
lost productivity, imposing a heavy economic burden on private
employers, private health plans, and federal, state, and local
governments. The cost of tobacco use to California is
estimated to be $18.1 billion annually. According to data from
2001 to 2010 published by the Centers for Disease Control and
Prevention in 2011, most smokers want to quit smoking (69%),
and over half (52%) tried to quit in the previous year, but
only 6% were successful.
3)Affordable Care Act Changes to Tobacco Cessation Coverage.
Section 2502 of the Patient Protection and Affordable Care Act
(ACA) prohibited drugs used to promote smoking cessation,
including agents approved by the FDA for over-the-counter for
purposes of promoting tobacco cessation, from being excluded
from Medicaid coverage. In addition, Section 4107 of the ACA
required Medicaid coverage of tobacco cessation counseling and
pharmacotherapy (FDA-approved OTC and prescription drugs) for
pregnant women, and prohibited cost-sharing for these
services.
The seven FDA-approved medications include five forms of
nicotine replacement therapy (NRT): the patch, gum, inhaler,
nasal spray, and lozenge, as well as two non-NRT medications,
bupropion SR (brand name Zyban if used for tobacco cessation
and Wellbutrin if used as an antidepressant), and varenicline
(brand name Chantix). Three forms of NRT - the patch, gum, and
the lozenge - are available OTC. The other two forms of NRT
(the inhaler and the nasal spray), as well as the two non-NRT
medications, are available by prescription. The patch is
available by prescription as well as OTC.
4)Tobacco use prevalence and current Medi-Cal coverage of
tobacco cessation. Medi-Cal beneficiaries have a higher
prevalence of tobacco use than the general California
population. In the 2011-12 California Health Interview Survey,
16.1% of adult and teen Medi-Cal beneficiaries were current
smokers, as compared to 12.1% of adults and teens not covered
by Medi-Cal. DHCS indicates expenditures on smoking deterrents
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in 2014 was $1 million in FFS and $3.1 million in managed
care. Coverage of tobacco cessation medication varies,
depending upon whether the beneficiary is in FFS Medi-Cal or
Medi-Cal managed care plan, and the particular Medi-Cal
managed care plan the beneficiary is enrolled in. In 2015-16,
Medi-Cal is projected to enroll 12.4 million individuals, of
whom 76.6% (9.5 million people) are projected to be in managed
care plans. For FFS Medi-Cal, DHCS is required to use the
following criteria when adding a drug to the Medi-Cal contract
drug list: (a) the safety of the drug; (b) the effectiveness
of the drug; (c) the essential need for the drug; (d) the
potential for misuse of the drug; and, (e) the cost of the
drug.
In September 2014, DHCS released Policy Letter 14-006 to provide
Medi-Cal managed care health plans with minimum requirements
for comprehensive tobacco cessation services. The main
differences between current DHCS policy and this bill is this
requires coverage for more quit attempts (4 quit attempts per
years vs. 2 per year in DHCS policy) and has broader coverage
of FDA-approved OTC products without prior authorization (this
bill requires coverage for all OTC products without prior
authorization, while DHCS policy requires coverage of at least
one OTC).
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
1)Minor administrative costs to update existing Medi-Cal
policies for the provision of smoking cessation services
(General Fund and federal funds).
2)Unknown costs due to increased utilization of smoking
cessation services. Under current practice, about 30,000
Medi-Cal beneficiaries access smoking cessation services at a
total annual cost of about $4 million per year. Assuming that
the expanded benefits required in the bill result in increased
demand for smoking cessation services of 10% to 20%, the bill
would result in increased costs of $400,000 to $800,000 per
year (General Fund and federal funds).
3)Unknown short term cost savings due to reduced smoking-related
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health care costs for Medi-Cal beneficiaries. A review of a
new smoking cessation benefit in the Massachusetts Medicaid
program indicates that reducing smoking by beneficiaries led
to a net reduction in health care costs of about $2 for each
$1 spent on the program. Using the assumptions for utilization
increase above, potential cost savings of $800,000 to $1.7
million per year. The long-term health care spending impacts
of reduced tobacco use are less clear, because reduced health
care spending on smoking-related conditions will be offset by
increased longevity.
SUPPORT: (Verified 8/28/15)
American Cancer Society Cancer Action Network (co-source)
American Heart Association/American Stroke Association
(co-source)
American Lung Association in California (co-source)
Association of California Healthcare Districts
Association of Northern California Oncologists
Biocom
California Academy of Physician Assistants
California Academy of Preventative Medicine
California Black Health Network
California Chapter of the American College of Emergency
Physicians
California Chronic Care Coalition
California Dental Association
California Healthcare Institute
California Life Sciences Association
California Medical Association
California Pan-Ethnic Health Network
California Society of Addiction Medicine
Community Clinic Association of Los Angeles County
County Health Executives Association of California
First 5 California
Health Officers Association of California
March of Dimes California Chapter
Medical Oncology Association of Southern California
Tobacco Education and Research Oversight Committee
Western Center on Law and Poverty
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OPPOSITION: (Verified8/28/15)
California Association of Health Plans
ARGUMENTS IN SUPPORT: This bill is jointly sponsored by the
American Heart Association/American Stroke Association, the
American Lung Association, and the American Cancer Society
Cancer Action Network to ensure all Medi-Cal patients are able
to access tobacco cessation treatments. The sponsors argue 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 noted 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 stated that Medi-Cal patients face barriers to
treatment services due to prior authorization and step therapy
treatment requirements. Supporters argue this bill provides
needed clarity for Medi-Cal participants on tobacco cessation
services and ensures access to comprehensive insurance coverage
for these services. Supporters conclude that increased access to
smoking cessation treatments and eliminating barriers will
reduce the incidence of tobacco-related diseases and will lower
health care costs.
ARGUMENTS IN OPPOSITION: The California Association of
Health Plans (CAHP) writes in opposition that this 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 DHCS. CAHP argues Medi-Cal managed
care plans already comply with the requirements of the DHCS
policy letter, and this bill will result in higher state costs
in Medi-Cal reimbursement rates to plans in order to reflect the
benefit expansion.
ASSEMBLY FLOOR: 67-12, 6/3/15
AYES: Achadjian, Alejo, Baker, Bloom, Bonilla, Bonta, Brown,
Burke, Calderon, Campos, Chau, Chávez, Chiu, Chu, Cooley,
Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier,
Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson,
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Gomez, Gonzalez, Gordon, Gray, Hadley, Harper, Roger
Hernández, Holden, Irwin, Jones-Sawyer, Lackey, Levine,
Linder, Lopez, Low, Maienschein, Mathis, McCarty, Medina,
Melendez, Mullin, Nazarian, O'Donnell, Olsen, Perea, Quirk,
Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth,
Mark Stone, Ting, Waldron, Weber, Wilk, Williams, Wood, Atkins
NOES: Travis Allen, Bigelow, Brough, Chang, Beth Gaines, Grove,
Jones, Kim, Mayes, Obernolte, Patterson, Wagner
NO VOTE RECORDED: Thurmond
Prepared by:Scott Bain / HEALTH /
8/31/15 16:46:54
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