State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2018–2022
Weekly / April 11, 2024 / 73(14);301–306
Anne DiGiulio1; Michael A. Tynan, MPH2; Anna Schecter, MPH2; Kisha-Ann S. Williams, MPH2; Brenna VanFrank, MD2 (View author affiliations)
View suggested citationSummary
What is already known about this topic?
More than one in five adults enrolled in Medicaid smokes cigarettes. Comprehensive, barrier-free insurance coverage of tobacco cessation treatments can increase smoking cessation.
What is added by this report?
From 2018 to 2022, the number of states with comprehensive Medicaid coverage of tobacco cessation treatment increased from 15 to 20; states with no treatment access barriers increased from two to three. Coverage gaps and access barriers remain in many states.
What are the implications for public health practice?
State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based tobacco cessation treatments and promoting this coverage to enrollees and providers.
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Abstract
The prevalence of cigarette smoking among U.S. adults enrolled in Medicaid is higher than among adults with private insurance; more than one in five adults enrolled in Medicaid smokes cigarettes. Smoking cessation reduces the risk for smoking-related disease and death. Effective treatments for smoking cessation are available, and comprehensive, barrier-free insurance coverage of these treatments can increase cessation. However, Medicaid treatment coverage and treatment access barriers vary by state. The American Lung Association collected and analyzed state-level information regarding coverage for nine tobacco cessation treatments and seven access barriers for standard Medicaid enrollees. As of December 31, 2022, a total of 20 state Medicaid programs provided comprehensive coverage (all nine treatments), an increase from 15 as of December 31, 2018. Only three states had zero access barriers, an increase from two; all three also had comprehensive coverage. Although states continue to improve smoking cessation treatment coverage and decrease access barriers for standard Medicaid enrollees, coverage gaps and access barriers remain in many states. State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based cessation treatments and by promoting this coverage to enrollees and providers.
Introduction
Although the prevalence of cigarette smoking among U.S. adults has been declining for decades (reaching 11.5% in 2021), tobacco-related disparities persist among population groups (1). In 2021, smoking prevalence among adults enrolled in Medicaid (21.5%) was higher than it was among adults with private insurance (8.6%) (1). In addition, although interest in quitting and quit attempts are similar among adults enrolled in Medicaid and those with private insurance, successful cessation prevalence is lower among those enrolled in Medicaid (2). The high prevalence of smoking in this population not only contributes to a substantial health burden for this population but also to the cost of health care. Smoking-attributable health care spending was $225 billion in 2014, more than one half of which was paid by Medicare and Medicaid (3).
Effective treatments for smoking cessation include seven Food and Drug Administration (FDA)–approved medications* as well as individual, group, and telephone counseling (4). The U.S. Surgeon General has concluded that “insurance coverage for smoking cessation treatment that is comprehensive, barrier-free, and widely promoted increases the use of these treatment services, leads to higher rates of successful quitting, and is cost-effective” (4). Although states are required to provide Medicaid expansion† enrollees with coverage for all tobacco cessation treatments,§ coverage for standard (i.e., traditional) Medicaid enrollees varies. Standard Medicaid enrollees are persons enrolled in Medicaid under traditional Medicaid eligibility criteria (e.g., low-income pregnant women, children, and persons with a disability), as opposed to Group XIII, or expansion, eligibility. Nationwide, approximately 80% of Medicaid enrollees are covered under standard Medicaid.¶ To assess cessation coverage policies among Medicaid programs, the American Lung Association collects state-level** information regarding coverage for nine tobacco cessation treatments†† and seven access barriers§§ for standard Medicaid enrollees.
Methods
During January 1, 2019, to December 31, 2022, the American Lung Association compiled data regarding state Medicaid tobacco cessation coverage from state Medicaid websites, Medicaid managed care plan member websites, provider websites, handbooks, policy manuals, plan formularies, preferred drug lists, Medicaid state plan amendments, regulations, and laws.¶¶ Analysts contacted personnel from state Medicaid agencies, state health departments, or other state government agencies to verify the information collected, retrieve missing documents, and reconcile discrepancies. Information provided by state personnel was considered accurate. As previously published, comprehensive coverage was defined as coverage of all nine assessed treatments (5). Barrier-free coverage was defined as having none of the seven assessed treatment access barriers. Summary statistics were generated and compared with data previously reported through December 31, 2018 (5). This activity was reviewed by CDC, deemed research not involving human subjects, and was conducted consistent with applicable federal law and CDC policy.***
Results
Coverage of Tobacco Cessation Treatment
As of December 31, 2022, all 50 states and the District of Columbia (DC) covered at least one cessation treatment for all standard Medicaid enrollees, which had not changed since December 31, 2018. As of December 2022, a total of 21 states covered both individual and group counseling for all standard Medicaid enrollees, an increase from 16 states in December 2018 (Table 1). Forty-three states covered all seven medications as of December 2022, an increase from 36 in December 2018 (Table 2). Two states (Delaware and Utah), which had covered all seven medications for all standard enrollees in 2018, no longer did so as of 2022 (four medications in Delaware and two medications in Utah changed from being covered for all standard enrollees to being covered for only some standard enrollees). All 15 states that had provided comprehensive coverage as of December 2018 maintained that coverage through December 2022. Five states (Illinois, New York, North Dakota, Pennsylvania, and Virginia) added comprehensive coverage during the study period.
Treatment Access Barriers
During December 2018–December 2022, the number of states with a treatment access barrier decreased for all seven barriers. For example, the number of states not requiring copayments increased from 28 to 39. However, some barriers continue to be common. As of December 2022, the three most common barriers (that apply to all or some standard Medicaid enrollees) were duration limits (39 states; 76%), annual limits on the number of covered quit attempts (35; 69%), and requirement for prior authorization (30; 59%) (Table 3). These three barriers were also the most common in December 2018. As of December 2022, only three states (Kentucky, Missouri, and Wisconsin) provided barrier-free coverage, an increase from two (Kentucky and Missouri) in December 2018. All three of these states provided comprehensive coverage.
Discussion
During 2018–2022, states continued to add coverage of tobacco cessation treatments and to remove treatment access barriers for standard Medicaid enrollees. However, coverage gaps and access barriers remain in many states. Although the number of states with comprehensive coverage increased from 15 in 2018 to 20 in 2022, this increase falls short of the Healthy People 2030 target of all 50 states and DC.††† In 2022, only three states provided coverage without any barriers. Increasing cessation coverage and decreasing barriers increases access to effective treatments that can increase the likelihood of successful quitting and improve health outcomes for persons who smoke (4).
The increase in the number of states with comprehensive treatment coverage and without barriers is likely related to state legislative actions. For example, Ohio passed legislation in 2020 requiring the state Medicaid program to cover a comprehensive cessation benefit with minimal barriers; Illinois passed similar legislation in 2021.§§§ These laws not only improve coverage and removed barriers, but also ensure that managed care plans will maintain this level of coverage in the future, even if new carriers are selected via competitive state bidding processes.
Laws like those passed in Ohio and Illinois can also help standardize tobacco cessation benefits across plans within a state. In the absence of such laws, treatment coverage and barriers can vary within a state’s Medicaid program, potentially limiting treatment access. Different Medicaid-managed care plans within a state can set different coverage policies. Consistent comprehensive coverage of tobacco cessation treatments with minimal barriers has the potential to increase standard Medicaid enrollees’ access to treatments and minimize confusion for both enrollees and providers.
Improved cessation treatment coverage observed in this study might also be related to some states¶¶¶ implementing Medicaid expansion during the study period (6). Many state Medicaid programs provide the same coverage for standard and expansion enrollees (7). Since states are required to provide expansion enrollees with coverage of all cessation treatments, consistency of coverage between standard and expansion plans might result in improvements in coverage for standard enrollees. Medicaid expansion has been shown to support cessation; states that have implemented Medicaid expansion have witnessed an increase in smoking cessation among lower-income adults (8,9). Opportunities remain for all states to improve coverage and increase promotion of available tobacco cessation benefits to encourage and support successful quitting.
This study demonstrates continued progress in decreasing tobacco cessation treatment access barriers for standard Medicaid enrollees. The biggest improvement in barrier removal was for copayments, with a nearly one third increase in the number of states without copayment requirements. One potential contributor to this change was enactment of the Families First Coronavirus Response Act (FFCRA),**** which increased the federal share of Medicaid spending by 6.2% with the requirement that states limit new cost-sharing for Medicaid enrollees. Continued monitoring of treatment access barriers remains important, particularly because the FFCRA maintenance of effort requirement, which limited cost-sharing, ended in 2023.†††† How this change in policy might affect access barriers for cessation treatments is unknown.
Limitations
The findings in this report are subject to at least two limitations. First, Medicaid-managed care plans can change with little notice and can vary widely between plans, which can make determining up-to-date coverage challenging. Second, information provided by state personnel could not be verified, potentially resulting in data misclassification.
Implications for Public Health Practice
More than one in five adults enrolled in Medicaid smoke cigarettes (1). Increasing comprehensive, barrier-free tobacco cessation insurance coverage for the more than 48 million adults enrolled in Medicaid§§§§ has the potential to reduce tobacco-related disparities in this population by increasing access to and usage of treatments that help persons quit smoking (4). By providing barrier-free coverage of all evidence-based tobacco cessation treatments, and promoting this coverage to enrollees and providers, state Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures.
Corresponding author: Brenna VanFrank, ydj5@cdc.gov.
1American Lung Association, Chicago, Illinois; 2Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Anne DiGiulio reports grants from Amgen, Novartis, the Pharmaceutical Research and Manufacturers of America, and the Biotechnology Innovation Organization. No other potential conflicts of interest were disclosed.
* These include five nicotine replacement therapies (nicotine patch, gum, lozenge, nasal spray, and oral inhaler) and two non-nicotine medications (bupropion and varenicline).
† Medicaid expansion, also known as Group XIII eligibility, provides Medicaid coverage to persons ineligible for standard Medicaid who have an income ≤138% of the federal poverty level. Medicaid expansion was created by the Patient Protection and Affordable Care Act and implemented in 2014. https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/
§ The Patient Protection and Affordable Care Act (ACA) requires Medicaid expansion plans to cover treatment given an “A” or “B” grade by the U.S. Preventive Services Task Force without cost-sharing (https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf). Tobacco cessation currently receives an “A” grade (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions) and is included in the ACA requirement (https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/aca_implementation_faqs19). Currently, this requirement is being legally challenged. https://www.kff.org/womens-health-policy/issue-brief/explaining-litigation-challenging-the-acas-preventive-services-requirements-braidwood-management-inc-v-becerra/
** The term “states” includes DC.
†† Treatments include seven FDA-approved smoking cessation medications and two types of counseling (individual and group). Telephone counseling was not examined because it is available free to callers (including Medicaid enrollees) via state quitlines in all 50 states and DC.
§§ Barriers to treatment include requirements for copayment, prior authorization, counseling for medications, and stepped care therapy, and limits on the duration and number (both annual and lifetime) of covered quit attempts. A barrier was considered to be in place if it existed for any of the nine assessed cessation treatments.
¶¶ Information on state Medicaid cessation coverage compiled by the American Lung Association is available in the CDC State Activities Tracking and Evaluation (STATE) System. Some data presented in this report differ from data available in the STATE System because of differences in coding rules, categories, and reporting periods. https://www.cdc.gov/statesystem
*** 45 C.F.R. part 46; 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d), 5 U.S.C. Sect. 552a, 44 U.S.C. Sect. 3501 et seq.
§§§ https://www.legislature.ohio.gov/legislation/133/hb11; https://www.ilga.gov/legislation/BillStatus.asp?DocNum=2294&GAID=16&DocTypeID=SB&SessionID=110&GA=102
¶¶¶ During the study period, Medicaid expansion occurred in Maine and Virginia (2019); Idaho, Nebraska, and Utah (2020); and Missouri and Oklahoma (2021).
**** The Centers for Medicare & Medicaid Services has issued guidance to states on implementing this provision (https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf). The FFCRA included a maintenance of effort requirement, meaning that states could not disenroll persons from Medicaid or impose new cost-sharing for Medicaid enrollees while the federal Medicaid payment was increased by 6.2%. www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf
†††† https://www.medicaid.gov/federal-policy-guidance/downloads/sho23002.pdf
§§§§ Includes both standard and expansion Medicaid enrollees. https://www.medicaid.gov/sites/default/files/2023-03/December-2022-medicaid-chip-enrollment-trend-snapshot.pdf
References
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Abbreviations: P = pregnant; V = varied coverage.
* “Yes” indicates treatment is covered for all standard Medicaid enrollees; “No” indicates treatment is not covered for any standard Medicaid enrollee; “V” indicates treatment coverage varies, with treatment covered for some, but not all, standard Medicaid enrollees; and “P” indicates treatment is covered for pregnant women only.
† Includes the District of Columbia.
§ As of December 31, 2018.
¶ As of December 31, 2022.
Abbreviation: V = varied coverage.
* “Yes” indicates treatment is covered for all standard Medicaid enrollees; “No” indicates treatment is not covered for any standard Medicaid enrollee; and “V” indicates treatment coverage varies, with treatment covered for some, but not all, standard Medicaid enrollees.
† Includes the District of Columbia.
§ As of December 31, 2018.
¶ As of December 31, 2022.
Abbreviations: NA = not available; V = varied coverage.
* Barriers apply to one or more cessation treatments.
† “Yes” indicates a barrier applies to all standard Medicaid enrollees; “No” indicates a barrier does not apply to any standard Medicaid enrollee; and “V” indicates a barrier applies to some, but not all, standard Medicaid enrollees.
§ Includes the District of Columbia.
¶ As of December 31, 2018.
** As of December 31, 2022.
Suggested citation for this article: DiGiulio A, Tynan MA, Schecter A, Williams KS, VanFrank B. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2018–2022. MMWR Morb Mortal Wkly Rep 2024;73:301–306. DOI: http://dx.doi.org/10.15585/mmwr.mm7314a2.
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