State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2008–2018

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), 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). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees† over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications§; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments.¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones 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 could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3-7).

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), 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). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees † over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications § ; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments. ¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers * FDA has approved seven medications for smoking cessation, including five nicotine replacement therapies (the nicotine patch, gum, lozenge, nasal spray, and inhaler) and two nonnicotine medications (bupropion and varenicline). † As used in this report, the term "traditional" Medicaid enrollees refers to persons who are enrolled in Medicaid under traditional Medicaid eligibility criteria (e.g., low-income pregnant women, children and persons with a disability), as opposed to the income-only eligibility criteria (i.e. income equal or less than 138% of the federal poverty level) for coverage under expanded Medicaid, created by the Patient Protection and Affordable Care Act and implemented in 2014. https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/. § Telephone counseling is available free to callers to state quitlines (including Medicaid enrollees) in all 50 states and DC through the national quitline portal 1-800-QUIT-NOW and was not included in 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. ¶ These seven coverage barriers are requirement of copayment, requirement of prior authorization, requirement of counseling for medications, stepped care therapy, limits on duration, annual limit on number of covered quit attempts, and lifetime limit on number of covered quit attempts. States were considered to have a barrier if that barrier was in place for one or more cessation treatments.
to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3)(4)(5)(6)(7).
During 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. † † As used in this report, the term "states" includes DC. Conversely, two states (Nebraska and Pennsylvania) that covered all nine cessation treatments in December 2008 no longer did so in December 2018. § § Thirteen (87%) of the 15 states that covered all nine cessation treatments in 2018 had barriers in place for some treatments (Table 3); the remaining two states (Kentucky and Missouri) have removed all seven barriers examined in this study. The number of states having none of the seven barriers to cessation treatment increased from zero to two during December 31, 2008-December 31, 2018. During this period, the number of states that did not require copayments for any cessation treatment for any traditional Medicaid enrollees approximately tripled, from 10 to 28. As of December 31, 2018, states reported that the most common barriers imposed on all or some traditional Medicaid enrollees were limits on duration of treatment (44 states, 86%), annual limits on quit attempts (37, 72%), and prior authorization requirements (35, 69%) (

Discussion
States made substantial progress in improving Medicaid coverage of proven tobacco cessation treatments during 2008-2018, with the number of states covering all nine cessation treatments for all traditional Medicaid enrollees increasing from six to 15 and the number of states covering all seven FDA-approved cessation medications increasing from 20 to 36. Improved coverage increases Medicaid enrollees' access to cessation treatments, which can make it easier for them to quit smoking (3,5,6). Covering all nine cessation treatments is important because different smokers respond better to or prefer different treatments than do other smokers.
The increase in the number of states covering all nine cessation treatments likely resulted in part from the Patient Protection and Affordable Care Act (ACA), which was passed in March 2010 (3). Two provisions of the ACA that introduced new requirements for state Medicaid cessation coverage took effect during the study period. The first provision, which took effect in October 2010, requires state Medicaid programs to cover cessation counseling and FDA-approved cessation     Totals  Yes  30  10  19  17  15  9  7  11  28  26  21  25  4  0  No  10  28  22  16  24  36  33  30  13  7  21  14  38  49  V  7  13  6  18  6  6  5  10  6  18  5  The combined use of counseling and medication is more effective in increasing quit rates than is the use of either of these treatments alone (3). Combined state Medicaid coverage of cessation counseling and medications has been found to be associated with an estimated mean increase in past-year quitting of 3.0 percentage points compared with that in persons without such coverage (5).
In addition, as of December 2018, all but two states retained barriers that make it more difficult for Medicaid enrollees to access cessation treatments. Removing these barriers would further increase Medicaid enrollees' access to and use of cessation treatments (3,6 made considerable progress in removing copayments during the study period, progress in removing other barriers was mixed. State Medicaid cessation coverage often varies considerably across a state's Medicaid managed care plans in terms of both cessation treatments covered and coverage barriers. Standardizing cessation coverage by having all managed care plans cover all proven cessation treatments with minimal barriers can be beneficial in maximizing Medicaid enrollees' access to proven cessation treatments while minimizing confusion about coverage among enrollees and providers. Standardizing coverage in this way is especially important because states are increasingly moving Medicaid enrollees from fee-for-service coverage into managed care coverage. ¶ ¶ ¶ The findings in this report are subject to at least two limitations. First, when official documents were not publicly available or were outdated or conflicting, state government personnel were contacted for clarification; however, it was not always possible to verify the accuracy of the information they provided. Second, cessation coverage can vary widely across Medicaid managed care plans and can change with little notice, which makes determining these plans' coverage challenging. Approximately 6.7 million adult smokers report being enrolled in Medicaid, accounting for approximately 20% of adult U.S. cigarette smokers.**** Whereas smokers enrolled in Medicaid are as likely as are privately insured smokers to want to quit and to make a past-year quit attempt, they are less ¶ ¶ ¶ https://www.kff.org/medicaid/state-indicator/share-of-medicaidpopulation-covered-under-different-delivery-systems/?currentTimeframe. **** This estimate includes enrollees in both traditional and expanded Medicaid, as determined in the 2018 National Health Interview Survey conducted by CDC's National Center for Health Statistics. https://www.cdc.gov/nchs/ nhis/data-questionnaires-documentation.htm. likely to succeed in quitting (9,10). Compared with smokers with private health insurance, smokers enrolled in Medicaid have been found to be more likely to have chronic diseases and to experience severe psychological distress (9). The high smoking prevalence among Medicaid enrollees imposes a substantial health burden on these persons and on society, and is a major driver of federal and state health care expenditures (3).
Smoking-related diseases accounted for approximately 15% of annual Medicaid spending during 2006-2010, amounting to approximately $39 billion in 2010 (2). State Medicaid programs can help reduce this health and financial burden by covering all evidence-based cessation treatments, removing coverage barriers, and promoting covered treatments to Medicaid enrollees and providers to increase their use (3)(4)(5)(6)(7).