STATE System Medicaid Coverage of Tobacco Cessation Treatments Fact Sheet

Background

Smoking is the leading preventable cause of premature death in the United States, resulting in about 480,000 deaths each year.1 More than 16 million Americans suffer from a disease caused by smoking.1 The Medicaid adult population smokes at a rate almost twice as high as that of the general population (27.8% Medicaid vs. 15.1%).2 Nationally, Medicaid spends about $40 billion on health care for smoking-related diseases annually—more than 15% of total Medicaid spending.1

The traditional Medicaid population is by definition low-income, and therefore less able to pay out-of-pocket for tobacco cessation treatments than people with higher incomes. Medicaid enrollees are also less likely than higher-income people to be able to successfully navigate the system to overcome barriers to accessing cessation treatments.3

While most smokers want to quit and many smokers try to quit each year, quitting smoking is difficult. Most smokers try to quit smoking several times before succeeding. One reason for this is that few smokers use cessation treatments that have been shown to increase quit rates.4,5 In 2015, 69.2% of adult smokers enrolled in Medicaid wanted to stop smoking, 56.3% tried to do so in the past year, but only 5.9% succeeded in quitting.5 Only 34.5% of smokers enrolled in Medicaid who tried to quit had used evidence-based counseling or medications, or both.5

What Works to Help Smokers Quit?

The US Public Health Service’s 2008 Clinical Practice Guideline on Treating Tobacco Use and Dependence4 recommends individual, group, and telephone counseling and seven FDA-approved prescription and over-the-counter medications as effective cessation treatments4. Insurance coverage of evidence-based cessation treatments leads to increases in quit attempts, use of cessation treatments, and successful cessation.4 In particular, more comprehensive state Medicaid coverage for cessation treatments appears to be associated with increased quit rates among smokers enrolled in Medicaid.6 Additionally, making cessation benefits more accessible to smokers on Medicaid by removing barriers to accessing cessation treatments such as cost-sharing and prior authorization would also be expected to increase the use of cessation treatments and successful quit attempts.4 Cost-sharing means any requirement that Medicaid enrollees pay for the treatment, including co-pays, deductibles, and coinsurance.

Evidence suggests that states could reduce smoking rates, smoking-related disease, and health care costs among Medicaid enrollees by providing Medicaid coverage for all evidence-based cessation treatments, removing all barriers to accessing these treatments, promoting the coverage, and monitoring its use.6,7,8,9

What are Medicaid Programs Required to Cover for Tobacco Cessation?

Traditional Medicaid vs. Medicaid Expansion
The Affordable Care Act establishes new income-based eligibility standards for Medicaid for states implementing Medicaid expansion. Plans offered to Medicaid enrollees who are newly eligible under this expansion (“expansion plans”) have different requirements for coverage than plans offered to those already enrolled in or eligible for Medicaid before 2014 (“traditional Medicaid”). The sections below address these different requirements.

Coverage of tobacco cessation counseling
The Affordable Care Act does not require state Medicaid programs to cover individual, group, or telephone cessation counseling for non-pregnant adult Medicaid enrollees. However, states can choose to cover these treatments. Coverage of individual counseling is typically provided through payments to health care providers. Group counseling can be covered in a variety of ways, such as through a separate wellness program vendor or by reimbursing health care providers for group sessions. Telephone counseling can be provided to Medicaid enrollees through state quitlines, and states can now receive federal administrative matching funds for this counseling. Medicaid expansion plans are subject to a different set of Affordable Care Act requirements, which require these plans to cover evidence-based preventive services, including tobacco cessation, with no cost-sharing.

Coverage for pregnant women
The Affordable Care Act has required Medicaid programs to cover tobacco cessation counseling and medications for pregnant women since October 2010. This requirement prohibits costsharing for covered counseling and medications. This provision has resulted in increases in state Medicaid coverage of cessation counseling and medications for pregnant women.10

Coverage of tobacco cessation medications
Beginning in January 2014, the Affordable Care Act prohibits state Medicaid programs from excluding any of the seven FDA-approved tobacco cessation medications from traditional Medicaid coverage. However, the provision does not require state Medicaid programs to remove barriers to accessing these medications. Medicaid expansion plans are subject to a different set of requirements. The Affordable Care Act requires these plans to cover evidence-based preventive services, including tobacco cessation, with no cost-sharing. A recent study found that only approximately 10% of Medicaid enrollees who smoked received a prescription for a tobacco cessation medication in 2013, with wide variation in use of cessation medications across states.11

Current State Medicaid Coverage of Tobacco Cessation Treatments

All state Medicaid programs cover some cessation treatments for all state Medicaid enrollees. However, only 15 states (California, Colorado, Connecticut, Indiana, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Missouri, Ohio, Oregon, Rhode Island, South Carolina, and Wisconsin) have comprehensive Medicaid coverage as of March 31, 2019. Kentucky and Missouri are the only states without any barriers in place to accessing any of these treatments.

Medicaid Coverage of Cessation Treatments (In effect as of June 30, 2019 (n=51))
Medicaid Coverage of Cessation Treatments (In effect as of June 30, 2019 (n=51))
State Individual Counseling Group Counseling Nicotine Patch Nicotine Gum Nicotine Lozenge Nicotine Nasal Spray Nicotine Inhaler Bupropion Varenicline Comprehensive Coverage
Alabama Varies No Yes Yes Yes Yes Yes Yes Yes No
Alaska Yes No Yes Yes Yes Yes Yes Yes Yes No
Arizona Varies No Yes Yes Yes Yes Yes Yes Yes No
Arkansas Yes No Yes Yes No No No Yes Yes No
California Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Colorado Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Connecticut Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Delaware Yes No Yes Yes Yes Yes Yes Yes Yes No
District of Columbia Yes No Yes Yes Yes Varies Varies Yes Varies No
Florida Varies Varies Yes Yes Yes No No Yes Yes No
Georgia Yes Varies Yes Yes Yes Varies Varies Yes Varies No
Hawaii Yes Varies Yes Yes Varies Varies Varies Yes Yes No
Idaho Yes No Yes Yes Yes Yes Yes Yes Yes No
Illinois Varies No Yes Yes Yes Varies Varies Yes Varies No
Indiana Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Iowa Varies Varies Yes Yes Yes Yes Yes Yes Yes No
Kansas Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Kentucky Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Louisiana Yes Varies Yes Yes Yes Varies Varies Yes Varies No
Maine Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Maryland Yes No Yes Yes Yes Yes Yes Yes Yes No
Massachusetts Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Michigan Yes Varies Yes Yes Yes Yes Yes Yes Yes No
Minnesota Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Mississippi Varies Varies Yes Yes Yes Yes Yes Yes Yes No
Missouri Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Montana Yes No Yes Yes Yes Yes Yes Yes Yes No
Nebraska Yes Varies Yes Yes Yes Yes Yes Yes Yes No
Nevada Varies Varies Yes Yes Yes Varies Yes Yes Yes No
New Hampshire Yes Varies Yes Yes Yes Yes Yes Yes Yes No
New Jersey Varies Varies Yes Yes Yes Varies Varies Yes Yes No
New Mexico Varies Varies Yes Yes Yes Varies Varies Yes Yes No
New York Yes Yes Yes Yes Yes Yes Varies Yes Yes No
North Carolina Yes No Yes Yes Yes Yes Yes Yes Yes No
North Dakota Varies No Yes Yes Yes Yes Yes Yes Yes No
Ohio Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Oklahoma Yes No Yes Yes Yes Yes Yes Yes Yes No
Oregon Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Pennsylvania Yes Varies Yes Yes Yes Varies Varies Yes Yes No
Rhode Island Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
South Carolina Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
South Dakota Varies No No No No No No Yes Yes No
Tennessee Varies No Yes Yes Yes Yes Yes Not Applicable Yes No
Texas Varies Varies Yes Yes Yes Yes Yes Yes Yes No
Utah Yes Varies Yes Yes Yes Yes Yes Yes Yes No
Vermont Yes No Yes Yes Yes Yes Yes Yes Yes No
Virginia Varies Varies Yes Yes Varies Varies Varies Yes Yes No
Washington Varies No Yes Yes Yes Varies Varies Yes Varies No
West Virginia Yes Varies Yes Yes Yes Yes Yes Yes Yes No
Wisconsin Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Wyoming Yes No Yes Yes Yes Yes Yes Yes Yes No

“Yes” means that the treatment is covered for all plans, including fee-for-service and managed care plans, if applicable. “No” means that the treatment is not covered.
“Varies” means that the coverage of treatment under both fee-for-service and managed care plans varies by plan or pregnancy status. Telephone counseling is not included because it 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. Coverage reported here is traditional Medicaid coverage, not coverage in Medicaid expansion plans.

Types of Counseling Recommended by the US Public Health Service and FDA-Approved Cessation Medications

Counseling

Barriers

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Access the full dataset on OSHData: Medicaid Coverage Of Cessation Treatments And Barriers To Treatments

2008-2019. American Lung Association. Cessation Coverage. Medicaid data compiled by the Centers for Disease Control and Prevention’s Office on Smoking and Health were obtained from the State Tobacco Cessation Coverage Database, developed and administered by the American Lung Association. Data from 2008-2012 are reported on an annual basis; beginning in 2013 data are reported on a quarterly basis. Data include state-level information on Medicaid coverage of approved medications by the Food and Drug Administration (FDA) for tobacco cessation treatment; types of counseling recommended by the Public Health Service (PHS) and barriers to accessing cessation treatment. Note: Section 2502 of the Patient Protection and Affordable Care Act requires all state Medicaid programs to cover all FDA-approved tobacco cessation medications as of January 1, 2014. However, states are currently in the process of modifying their coverage to come into compliance with this requirement. Data in the STATE System on Medicaid coverage of tobacco cessation medications reflect evidence of coverage that is found in documentable sources, and may not yet reflect medications covered under this requirement.

References

1. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic DiseasePrevention and Health Promotion, Office on Smoking and Health; 2014.

2. Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, Graffunder CM. Current cigarette smoking among adults—United States, 2005–2015. MMWR Morb Mortal Wkly Rep 2016;65:1205–11.

3. Saunders MR, Alexander C. Turning and churning: loss of health insurance among adults in Medicaid. J Gen Intern Med. 2009;24:133–34.

4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline.pdf iconexternal icon Rockville, MD: US Department of Health and Human Services, Public
Health Service; 2008. Accessed September 16, 2014.

5. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults—United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017;65:1457–1464.

6. Greene J, Sacks RM, McMenamin SB. The impact of tobacco dependence treatment coverage and copayments in Medicaid. Am J Prev Med. 2014;46:331–6.

7. Land T, Warner D, Paskowsky M, et al. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS ONE. 2010;5:e9770.

8. Land T, Rigotti NA, Levy DE, et al. A longitudinal study of Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular diseases. PLoS Med 2010;7:e1000375.

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

10. 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.

11. Ku L, Bruen BK, Steinmetz E, Bysshe T. Medicaid tobacco cessation: big gaps remain in efforts to get smokers to quit. Health Aff (Millwood) 2016;35:62–70.

12. Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed September 15, 2015. Available from:

DISCLAIMER: The STATE System contains data synthesized from state-level statutory laws. It does not contain state-level regulations; measures implemented by counties, cities, or other localities; opinions of Attorneys General; or relevant case law decisions for tobacco control topics other than preemption; all of which may vary significantly from the laws reported in the database, fact sheets, and publications.