BILL ANALYSIS Ó AB 1696 Page 1 ASSEMBLY THIRD READING AB 1696 (Holden) As Amended May 31, 2016 Majority vote ------------------------------------------------------------------ |Committee |Votes|Ayes |Noes | | | | | | | | | | | | | | | | |----------------+-----+----------------------+--------------------| |Health |17-1 |Wood, Maienschein, |Patterson | | | |Bonilla, Burke, | | | | |Campos, Dababneh, | | | | |Cooley, Roger | | | | |Hernández, Lackey, | | | | |Nazarian, Olsen, | | | | |Ridley-Thomas, | | | | |Rodriguez, Santiago, | | | | |Steinorth, Thurmond, | | | | |Waldron | | | | | | | |----------------+-----+----------------------+--------------------| |Appropriations |14-6 |Gonzalez, Bloom, |Bigelow, Chang, | | | |Bonilla, Bonta, |Gallagher, Jones, | | | |Calderon, Daly, |Obernolte, Wagner | | | |Eggman, Eduardo | | | | |Garcia, Roger | | | | |Hernández, Holden, | | | | |Quirk, Santiago, | | | | |Weber, Wood | | AB 1696 Page 2 | | | | | | | | | | ------------------------------------------------------------------ SUMMARY: Requires Medi-Cal to cover tobacco cessation services. Specifically, this bill: 1)Requires that the tobacco cessation services covered under Medi-Cal be subject to utilization controls. 2)Requires tobacco cessation services to include all intervention recommendations assigned a grade A or B by the United States Preventive Services Task Force (USPSTF). 3)Requires tobacco cessation services to include the following: a) A minimum of four quit attempts per year, with no required break between attempts, for all beneficiaries 18 years of age or older who use tobacco; b) For beneficiaries under 18 years of age, be provided services in accordance with the American Academy of Pediatrics guidelines and intervention recommendations, assigned a grade A or B by the USPSTF; c) At least four tobacco cessation counseling sessions per quit attempt, as specified, at the option of the beneficiary; and, d) A 12-week treatment regimen of any medication approved by the federal Food and Drug Administration (FDA) for AB 1696 Page 3 tobacco cessation, including prescription and over-the-counter (OTC) medications, with at least one prescription and all OTC medications made available without prior authorization, as specified. 4)Specifies that beneficiaries who are covered under this bill shall not be required to receive a particular form of tobacco cessation service as a condition of receiving any form or tobacco cessation service. 5)Requires the Department of Health Care Services (DHCS) to seek any federal approvals necessary to implement the provisions of this bill. Provides that this bill is only to be implemented to the extent that federal financial participation is available and not otherwise jeopardized and that the state has obtained all necessary federal approvals. 6)Requires DHCS, by December 31, 2017, to issue guidelines and enter into an agreement that authorizes the California Smokers' Helpline or its successor, as administered by the Department of Public Health, to directly furnish at least one form of OTC nicotine replacement therapy as described by USPSTF to Medi-Cal beneficiaries enrolled in smoking cessation services provided by the state tobacco use cessation quit line. 7)Requires the guidelines specified in 5) above to address requirements for pharmacists and physicians in furnishing nicotine replacement products under this bill to be consistent with existing requirements that applies to pharmacists. 8)Requires DHCS, by December 1, 2017, to include medical assistance with smoking and tobacco use cessation rates among adults enrolled in Medi-Cal managed care plans in its AB 1696 Page 4 Healthcare Effectiveness Data and Information Set (HEDIS). Authorizes DHCS to use data collected under this bill for quality improvement projects to increase cessation by Medi-Cal enrollees who use tobacco products. 9)Prohibits tobacco status to be used by DHCS or MCPs to deny coverage or treatment of tobacco-related illnesses. 10)Provides that this bill will be implemented only to the extent federal financial participation is available, as specified. FISCAL EFFECT: According to the Assembly Appropriations Committee: 1)Increased 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 (GF)/federal). 2)Short term cost savings due to reduced smoking-related health care costs for Medi-Cal beneficiaries. A review of a 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 $1.6 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 AB 1696 Page 5 people living longer, though such "costs" are generally considered societally beneficial. 3)Minor administrative costs to update existing Medi-Cal policies for the provision of smoking cessation services (GF/ federal). 4)If a new billing process is required to administer the provision of over-the-counter nicotine patches to Medi-Cal beneficiaries, potentially significant administrative costs to DHCS (GF/federal). 5)Unknown, potentially significant costs to DHCS to add a tobacco-related measure to the HEDIS survey that is administered for health plans (GF/federal). COMMENTS: According to the author, quitting tobacco products is a difficult feat that many individuals attempt every year with little success on their own. The author states tobacco products can cause cancer, respiratory and heart diseases, and birth defects, and their use is still the leading preventable cause of death in the United States. The author contends that though the dangers of smoking are better understood now than 50 years ago, cigarettes are addictive and smoking rates in the Medi-Cal population are still too high. The author asserts this bill provides smokers with the tools necessary to fight their addiction to tobacco products by mandating Medi-Cal coverage to clinically proven treatments. The author maintains that studies have shown that the comprehensive coverage of these treatments has led to decreases in the population of smokers. The author concludes that the state must remove all barriers to treatments that make quitting the use of tobacco products possible. On September 3, 2014, DHCS released policy letter 14-006 to AB 1696 Page 6 provide managed care plans (MCPs) with minimum requirements for comprehensive tobacco cessation services. The requirements, similar to federal guidance on the issue, are for the following: 1)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; 2)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; 3)MCPs may not require members to attend counseling sessions or classes prior to receiving a prescription for an FDA-approved tobacco cessation medication; 4)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, 5)Four counseling sessions of at least 10 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. Notable differences between the requirements of this bill and AB 1696 Page 7 the requirements under DHCS' policy on coverage of tobacco cessation products include a minimum requirement under the DHCS policy and federal guidance for the length of counseling sessions, and a modestly increased treatment regimen (90 days under federal guidance and DHCS policy vs. 84 days under this bill). This bill also requires coverage for a minimum of four quit attempts per year, with no required break between attempts, for all Medi-Cal beneficiaries 18 years of age and older who use tobacco, whereas federal guidance and DHCS policy states coverage should be for at least two quit attempts. Finally, this bill requires all OTC medications and at least one prescription medication be available without prior authorization, whereas the DHCS policy is to cover all seven FDA-approved tobacco cessation products, at least one of which must be available without prior authorization. Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0003274