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 Adults enrolled in Medicaid smoke cigarettes at a rate more than twice as high as that of privately insured adults (23.9% vs. 10.5%, respectively).2 Nationally, Medicaid spends about $40 billion on health care for smoking-related diseases annually—more than 15% of total Medicaid spending.1 Smoking cessation improves health status, enhances quality of life, reduces the risk of premature death, and can add as much as a decade to life expectancy.3 Smoking cessation also reduces the substantial financial burden that smoking places on smokers, health care systems, and society.3

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.4

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 when trying to quit.3,5 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?

Smoking cessation medications approved by the U.S. Food and Drug Administration and behavioral counseling are cost-effective cessation strategies. Cessation medications approved by the U.S. Food and Drug Administration and behavioral counseling increase the likelihood of successfully quitting smoking, particularly when used in combination.3 Using combinations of nicotine replacement therapies can further increase the likelihood of quitting.3  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.3  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.3 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.3,6,7,8,9

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 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 cost sharing 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 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 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 13 states (California, Colorado, Connecticut, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Missouri, Ohio, Oregon, Rhode Island, and South Carolina) have comprehensive Medicaid coverage as of December 31, 2019. Kentucky, Missouri, and Wisconsin are the only states without any barriers in place to accessing any of these treatments.

Medicaid Coverage of Cessation Treatments (In effect as December 31, 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 No Varies 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 Yes No
Florida Varies Varies Varies Yes Varies No No Yes Yes No
Georgia No 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 Varies Varies Varies Yes Yes No
Indiana Varies Varies Yes Yes Yes Yes Yes Yes Yes No
Iowa Varies No 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 Yes Yes Yes Yes No
Maine Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Maryland Varies Varies Yes Yes Yes Yes Yes Yes Yes No
Massachusetts Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Michigan Varies 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 No Yes Yes Yes Yes Yes Yes Yes No
Nevada Varies Varies Yes Yes Yes Varies Varies Yes Varies No
New Hampshire Varies Varies Yes Yes Yes Yes Yes Yes Yes No
New Jersey Not Available Varies Yes Varies Yes Varies Varies Yes Yes No
New Mexico Yes No Yes Yes Yes Yes Yes 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 Yes 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 Yes Yes No
Texas Yes 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 No Yes Yes Yes Varies Varies Yes Yes No
Washington Varies No Yes Yes Yes Yes Yes Yes Yes No
West Virginia Yes Varies Yes Yes Yes Yes Yes Yes Yes No
Wisconsin Yes No Yes Yes Yes Yes Yes Yes Yes No
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

Individual, group and telephone counseling. Medications include nicotine patch, nicotine gum, nicotine lozenge, nicotine nasal spray, nicotine inhaler, bupropion, and varenicline

Barriers to Cessation treatment - Required Co-payments, Prior authorization requirements, limits on treatment duration, yearly or lifetime limits, stepped-care therapy

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 Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.

2. Creamer MR, Wang TW, Babb S, Cullen KA, Day H, Willis G, Jamal A, Neff L. Tobacco product use and cessation indicators among adults—United States, 2018. pdf icon[PDF – 219 KB] MMWR Morb Mortal Wkly Rep 2019;68:1013-1019

3. U.S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2020.pdf iconexternal icon

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

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. Kostova D, Xu X, Babb S, McMenamin SB, King BA. Does state Medicaid coverage of smoking cessation treatments affect quitting? Health Serv Res 2018; 53(6):4725-46.

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.

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.