State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2015–2017

Anne DiGiulio; Zach Jump, MA; Annie Yu; Stephen Babb, MPH; Anna Schecter, MPH; Kisha-Ann S. Williams, MPH; Debbie Yembra, MPH; Brian S. Armour, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(13):390-395. 

In This Article

Abstract and Introduction

Introduction

Cigarette smoking prevalence among Medicaid enrollees (25.3%) is approximately twice that of privately insured Americans (11.8%), placing Medicaid enrollees at increased risk for smoking-related disease and death.[1] Medicaid spends approximately $39 billion annually on treating smoking-related diseases.[2] Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)–approved medications* are effective in helping tobacco users quit.[3] Although state Medicaid coverage of tobacco cessation treatments improved during 2014–2015, coverage was still limited in most states.[4] To monitor recent changes in state Medicaid cessation coverage for traditional (i.e., nonexpansion) Medicaid enrollees, the American Lung Association collected data on coverage of a total of nine cessation treatments: individual counseling, group counseling, and seven FDA-approved cessation medications in state Medicaid programs during July 1, 2015–June 30, 2017. The American Lung Association also collected data on seven barriers to accessing covered treatments, such as copayments and prior authorization. As of June 30, 2017, 10 states covered all nine of these treatments for all enrollees, up from nine states as of June 30, 2015; of these 10 states, Missouri was the only state to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers would be expected to reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures.[5–7]

During July 2015–June 2017, the American Lung Association compiled data on state Medicaid tobacco cessation coverage from state Medicaid and Medicaid managed care plan member and provider websites and handbooks, policy manuals, plan formularies and preferred drug lists, Medicaid state plan amendments, and relevant regulations and laws.§ Analysts searched for mentions of the nine cessation treatments using search functions on state Medicaid websites and other relevant state-sponsored websites and the Google search engine. The American Lung Association contacted personnel from state Medicaid agencies, state health departments, or other state government agencies to give them the opportunity to verify the information collected and to retrieve missing documents and reconcile discrepancies.

As of June 30, 2017, 10 states (California, Connecticut, Indiana, Maine, Massachusetts, Minnesota, Missouri, New York, Ohio, and Vermont) covered all nine cessation treatments for all Medicaid enrollees, an increase from nine states in June 2015 (Table 1) (Table 2). Three states (California, Missouri, and New York) achieved this level of coverage during the study period. Conversely, North Dakota and Pennsylvania, which covered all nine cessation treatments in June 2015, no longer did so in June 2017. As of June 30, 2017, nine of the 10 states that covered all cessation treatments had barriers in place for some treatments (Table 3); the remaining state, Missouri, has removed all barriers examined in this study. Two additional states (Kentucky and South Carolina) achieved comprehensive coverage effective July 1, 2017, after conclusion of the study period; Kentucky also removed all barriers to accessing the nine cessation treatments.**

As of June 30, 2017, all 50 states and the District of Columbia (DC) covered at least some cessation treatments for all Medicaid enrollees, compared with 48 states in June 2015. As of June 30, 2017, 32 states covered all seven FDA-approved cessation medications for all enrollees, up from 30 states in June 2015 (Table 2). Thirty-three states covered individual counseling as of June 30, 2017, with 10 of these states covering group counseling as well, compared with 31 states and 10 states, respectively, as of June 2015 (Table 1).

During July 1, 2015–June 30, 2017, 13 states removed copayments for cessation treatments for at least some Medicaid enrollees, and the number of states that do not require copayments for any cessation treatment for any Medicaid enrollees increased from 16 to 27 states. As of June 30, 2017, the most common barriers were limits on duration (with 41 states reporting this barrier for at least certain populations or plans), prior authorization requirements (38 states), annual limits on quit attempts (34 states), and required copayments (24 states) (Table 3).

*These medications include the nicotine patch, gum, lozenge, nasal spray, and inhaler and bupropion and varenicline.
Telephone counseling is available free to callers to state quitlines (including Medicaid enrollees) in all 50 states and the District of Columbia through the national quitline portal 1–800-QUIT-NOW, and therefore is not captured by this report. In June 2011, the Centers for Medicare & Medicaid Services announced that it would offer a 50% federal administrative match to state Medicaid programs for the cost of state quitline counseling provided to Medicaid enrollees.
§Information on state Medicaid cessation coverage compiled by the American Lung Association is available in the CDC State Activities Tracking and Evaluation (STATE) System, a database that contains tobacco-related epidemiologic and economic data and information on state tobacco-related legislation (https://www.cdc.gov/statesystem). Certain data presented in this report differ slightly from Medicaid cessation coverage data reported in the STATE System because of small differences in coding rules, categories, and reporting periods.
These two states are no longer considered to provide comprehensive Medicaid cessation coverage because of a change in how cessation counseling benefits are administered in North Dakota and the addition of a new Medicaid managed care plan in Pennsylvania that did not provide comprehensive coverage.
**Kentucky achieved comprehensive Medicaid cessation coverage and removed barriers impeding Medicaid enrollees' access to cessation treatments by enacting a state law (Ky. Rev. Stat. Ann. Sect. 205) that also applied to private cessation insurance coverage. South Carolina achieved comprehensive Medicaid cessation coverage by issuing a Medicaid bulletin (https://www.scdhhs.gov/press-release/tobacco-cessation-coverage).

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