State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage – United States, 2014-2015

Medicaid enrollees have a cigarette smoking prevalence (30.4%) twice as high as that of privately insured Americans (14.7%), placing them at increased risk for smoking-related disease and death (1). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications are evidencebased, effective treatments for helping tobacco users quit (2). A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of these treatments.* [dagger] * * However, a previous MMWR report indicated that, although state Medicaid coverage of cessation treatments had improved during 2008-2014, this coverage was still limited in most states (3). To monitor the most recent trends in state Medicaid cessation coverage, the American Lung Association collected data on coverage of, and barriers to, accessing all evidence-based cessation treatments except telephone counseling[dagger] in state Medicaid programs (for a total of nine treatments) during January 31, 2014-June 30, 2015. As of June 30, 2015, all 50 states covered certain cessation treatments for at least some Medicaid enrollees. During 2014-2015, increases were observed in the number of states covering individual counseling, group counseling, and all seven FDA-approved cessation medications for all Medicaid enrollees; however, only nine states covered all nine treatments for all enrollees. Common barriers to accessing covered treatments included prior authorization requirements, limits on duration, annual limits on quit attempts, and required copayments. Previous research in both Medicaid and other populations indicates that state Medicaid programs could reduce smoking prevalence, smoking-related morbidity, and smoking-related health care costs among Medicaid enrollees by covering all evidence-based cessation treatments, removing all barriers to accessing these treatments, promoting coverage to Medicaid enrollees and health care providers, and monitoring use of covered treatments (2,4-7).

To assess state Medicaid tobacco cessation coverage, during August 2014-June 2015, the American Lung Association compiled data from Medicaid member websites and handbooks, Medicaid provider websites and handbooks, Medicaid policy manuals, preferred drug lists/formularies, and relevant regulations and legislation. Researchers searched for mentions of the nine cessation treatments considered in this study by using search functions on state Medicaid websites, other relevant state-sponsored websites, and the Google search engine. These data were then confirmed through consultations with staff members of state Medicaid agencies and health departments, or other knowledgeable state government personnel. Consultations were also used to supply missing documents and reconcile discrepancies. A state Medicaid program or managed care plan was only considered to cover a tobacco cessation treatment if documentation was available for this coverage. Information on state Medicaid cessation coverage compiled by the American Lung Association is available on 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.§

As of June 2015, nine states (Connecticut, Indiana, Maine, Massachusetts, Minnesota, North Dakota, Ohio, Pennsylvania, and Vermont) cover all nine evidence-based cessation treatments considered in this study for all Medicaid enrollees, up from six states in January 2014.¶ Maine, North Dakota, and Ohio achieved this level of coverage during the study period. However, all nine states with this level of coverage have barriers, such as copayments (seven of nine states) or prior authorization requirements (seven of nine states), in place for some treatments. As of June 2015, 31 states covered individual counseling for all populations and plans (up from 27 in 2014), and 10 states covered group counseling for all populations and plans (up from seven in 2014) (Table 1). Additionally, 30 states covered all seven FDAapproved cessation medications for all populations and plans (up from 26 states in 2014) (Table 2). The most common barriers included prior authorization requirements (with 39 states reporting this barrier for at least certain populations or plans), limits on duration (38 states), annual limits on quit attempts (36 states), and required copayments (34 states) (Table 3).

Discussion

Although some progress in state Medicaid coverage of proven tobacco cessation treatments occurred during the study period, only nine states cover all nine treatments considered in this report for all Medicaid enrollees. Moreover, all of these states still have some barriers in place that make it more difficult for Medicaid enrollees to access these treatments, which would be expected to impede use of these treatments, quit attempts, and successful cessation (2). Removing these barriers increases access to and use of cessation treatments for both Medicaid enrollees and other populations (2,5). Comprehensive Medicaid tobacco cessation coverage with minimal barriers has the potential to help more Medicaid enrollees quit tobacco (4,5). Continued efforts by state Medicaid programs to increase coverage and use of evidence-based cessation treatments would be expected to result in improved health outcomes among Medicaid enrollees and reduced Medicaid health care costs (6,7).

Insurance coverage of evidence-based cessation treatments leads to increases in quit attempts, use of cessation treatments, and successful smoking cessation (2). One study determined that more comprehensive state Medicaid coverage for cessation treatments was associated with increased quit rates among smokers enrolled in Medicaid (4).

Effective January 2014, section 2502 of the 2010 Patient Protection and Affordable Care Act barred state Medicaid programs from excluding FDA-approved cessation medications from coverage.** [dagger][dagger] * §§,[dagger][dagger] The Centers for Medicare and Medicaid Services has issued guidance to states on implementing this provision.§§,¶¶,*** This study finds that some states have improved their coverage of cessation medications during the study period. Other states might have improved this coverage before the study period in response to this provision. State Medicaid programs can maximize the effect of this provision on cessation by placing tobacco cessation medications on preferred drug lists (or similar documents), removing barriers to accessing these medications, and adding notices of coverage to public plan documents (9). State Medicaid programs can also increase cessation among Medicaid enrollees by covering cessation counseling along with cessation medications, because the combined use of these treatments is more effective in increasing quit rates than the use of either alone (2).

The findings in this report are subject to at least four limitations. First, 2015 data were not available for the District of Columbia. Second, in cases where official documents were not publicly available or conflicted with one another, knowledgeable state government personnel were consulted to provide non-public documentation or resolve discrepancies; this information might have been inaccurate in some cases. Third, cessation coverage can vary widely across Medicaid managed care plans, making it difficult to determine the coverage provided by specific plans in practice. Finally, this report does not assess promotion, awareness, or use of state Medicaid cessation coverage. The extent to which smokers use covered treatments is a key factor in determining the effect of cessation coverage, and promotion and awareness of coverage in turn determine the level of use. Although examining these factors is important to accurately evaluate the impact of a state's Medicaid cessation coverage, this type of data is not currently available in most states. It is important to identify an approach to obtain information on use of cessation treatments by Medicaid enrollees.

Although state Medicaid cessation coverage improved during 2014-2015, coverage still falls substantially short of the Healthy People 2020 target of full coverage in all 50 states and the District of Columbia; almost six million Medicaid enrollees continue to smoke cigarettes (1). Smoking-related diseases accounted for approximately 15% of annual Medicaid spending during 2006-2010, amounting to more than $39 billion per year (10).

State Medicaid programs can maximize tobacco cessation among Medicaid enrollees by covering all evidence-based cessation treatments, removing barriers that impede access to these treatments, promoting their coverage to Medicaid tobacco users and health care providers, and monitoring use of covered treatments (5-7). State Medicaid programs that take these actions have the potential to substantially reduce tobacco use, tobacco-related disease, and health care costs among Medicaid enrollees.

Acknowledgments

Paul G. Billings, Susan J. Rappaport, Kim Lacina, Erika Sward, Katherine Pruitt, Bill Blatt, Thomas Carr, Allison MacMunn, Gregg Tubbs, Catherine Fields Chandler, Meredith Haddix, American Lung Association National Office, Washington, DC; American Lung Association; Suzanne R. Abbott, Heather Smith, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Summary

What is already known on this topic?

Medicaid enrollees smoke cigarettes at a higher rate than privately insured U.S. residents. Comprehensive state Medicaid cessation coverage has the potential to reduce smoking, smoking-related disease, and health care costs among Medicaid enrollees. Although state Medicaid coverage of cessation treatments had improved during 2008-2014, this coverage was still limited in most states.

What is added by this report?

Although state Medicaid cessation coverage improved during 2014-2015, coverage continues to fall substantially short of the Healthy People 2020 target of full coverage in all 50 states and the District of Columbia. As of June 2015, only nine states cover all nine evidence-based cessation treatments considered in this study for all Medicaid enrollees, up from six states in 2014. All of these states have barriers to accessing some treatments.

What are the implications for public health practice?

State Medicaid programs can help more Medicaid enrollees quit tobacco use by covering all evidence-based cessation treatments, removing barriers that make it difficult for enrollees to access these treatments, promoting cessation coverage, and monitoring use of covered treatments. State Medicaid programs can enhance the effect of the Affordable Care Act provision barring state Medicaid coverage from excluding cessation medications by placing these medications on preferred drug lists, removing barriers to accessing these medications, and covering cessation counseling as well as medications.

* Additional information available at http://www.healthypeople.gov/2020/topicsobjectives/topic/tobacco-use/objectives.

[dagger] 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 and 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.

§ Additional information available at http://www.cdc.gov/statesystem. Certain data presented in this report differ slightly from Medicaid cessation coverage data reported in the STATE System because of slightly different coding rules, categories, and reporting periods.

¶ Nevada was previously reported to cover all nine treatments considered in this report (3); however, researchers have since found that the Nevada Medicaid program does not cover group counseling.

** Patient Protection and Affordable Care Act of 2010. Pub. L. No. 114-48 (March 23, 2010), as amended through May 1, 2010. Available at http:// docs.house.gov/energycommerce/ppacacon.pdf.

[dagger][dagger] Affordable Care Act provision section 4107 required state Medicaid programs to cover tobacco cessation counseling and pharmacotherapy for pregnant women with no cost-sharing, effective October 2010, which has resulted in increased state Medicaid coverage of cessation counseling and medications for pregnant women (8).

§§ Additional information available at http://www.medicaid.gov/medicaidchip-program-information/by-topics/benefits/prescription-drugs/ downloads/rx-releases/state-releases/state-rel-165.pdf.

¶¶ As of October 23, 2015, the Centers for Medicare and Medicaid Services had published State Plan Amendments from 36 states declaring that they have implemented this provision.

** In addition to the Affordable Care Act provisions mentioned in this report, this legislation, as written, also provides strong incentives for all states to expand eligibility for Medicaid coverage. Although the Supreme Court ruling in June 2012 held that a state cannot lose federal funding for its existing Medicaid program if it does not participate in the expansion, 30 states and the District of Columbia have expanded Medicaid as of October 23, 2015 (http://kff.org/health-reform/slide/ current-status-of-the-medicaid-expansion-decision). This is expected to further increase the number of smokers who have access to cessation treatments in expansion states; however, information for a comprehensive evaluation of cessation coverage in the Medicaid expansion population is not currently available.

References

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2. US Public Health Service. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: US Department of Health and Human Services, US Public Health Service; 2008. Available at http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/index.html.

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7. Richard P, West K, Ku L. The return on investment of a Medicaid tobacco cessation program in Massachusetts. PLoS One 2012;7:e29665.

8. McMenamin SB, Halpin HA, Ganiats TG. Medicaid coverage of tobacco-dependence treatment for pregnant women: impact of the Affordable Care Act. Am J Prev Med 2012;43:e27-9.

9. McAfee T, Babb S, McNabb S, Fiore MC. Helping smokers quit- opportunities created by the Affordable Care Act. N Engl J Med 2015;372:5-7.

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Jennifer Singleterry, MA1; Zach Jump, MA1; Anne DiGiulio1; Stephen Babb, MPH2; Karla Sneegas, MPH2; Allison MacNeil, MPH2; Lei Zhang, PhD2; Kisha-Ann S. Williams2

1American Lung Association; 2Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Corresponding author: Stephen Babb, [email protected], 770-488-1172.