State Medicaid Coverage for Tobacco-Dependence Treatments—United States, 2009 FREE

MMWR. 2010;59:1340-1343

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Medicaid enrollees have nearly twice the smoking rates (37%) of the general adult population (21%), and smoking-related medical costs are responsible for 11% of Medicaid expenditures.^{1 - 2} In 2008, the Public Health Service released clinical practice guidelines recommending comprehensive coverage of effective tobacco-dependence medications and counseling by health insurers.³ Healthy People 2010 established a clear objective for Medicaid programs to cover all Food and Drug Administration—approved medications and counseling for tobacco cessation.⁴ To monitor progress toward that objective, the Center for Health and Public Policy Studies at the University of California, Berkeley, in collaboration with CDC, surveyed Medicaid programs in the 50 states and the District of Columbia (DC) to document their 2009 tobacco-dependence treatment coverage and found that 47 programs offered coverage. Only eight state programs offered coverage of all recommended pharmacotherapy and counseling for all Medicaid enrollees, and 16 programs reported coverage for fee-for-service enrollees that differed from that provided for Medicaid managed-care enrollees. Among the 33 programs that covered at least one combination therapy, the nicotine patch plus bupropion slow release (SR) was the one combination covered by all. The Affordable Care Act mandates Medicaid coverage of tobacco-dependence treatments⁵ for pregnant women, beginning October 1, 2010. Coverage of pharmacotherapy for all Medicaid enrollees will be enhanced by January 2014, when states no longer may exclude tobacco-dependence cessation drugs from covered benefits. Monitoring the extent to which Medicaid programs place limitations on these treatments can help in evaluating accessibility of tobacco-dependence treatments to Medicaid enrollees.

Medicaid coverage of tobacco-dependence treatments has been assessed regularly since 1998 by the University of California, Berkeley. In November 2009, a link to an online survey instrument was sent to previously identified Medicaid personnel for the 50 state Medicaid programs and DC. Respondents were asked to complete 45 questions regarding treatment coverage, coverage limitations, outreach activities, and related subjects. Follow-up questions were directed to relevant contacts in each state via telephone or e-mail. The response rate was 100%. To validate survey responses, Medicaid programs were asked to submit documentation of their tobacco-dependence treatment coverage policies. Of the 47 programs that indicated they covered at least one tobacco-dependence treatment, supporting documentation was obtained for 44 (94%) programs. For programs without complete documentation, the information given by the respondent was confirmed with a second respondent within that state before being accepted as accurate.

Among the 51 Medicaid programs, 47 provided tobacco-dependence treatment coverage for some enrollees, 38 covered at least one tobacco-dependence treatment for all Medicaid enrollees, and four (Connecticut, Georgia, Missouri, and Tennessee) offered no coverage for tobacco-dependence treatment to their enrollees. Coverage for all enrollees was defined as coverage that did not differ between fee-for-service (FFS) and managed-care organization (MCO) enrollees. Coverage for all Medicaid enrollees was reported for the nicotine patch (34 programs), bupropion or Zyban* (33 programs), nicotine gum (32 programs), varenicline (Chantix) (32 programs), nicotine nasal spray (28 programs), nicotine inhalers (27 programs), and nicotine lozenges (25 programs). Only five states (Indiana, Massachusetts, Minnesota, Montana, and Pennsylvania) reported having policies that require coverage of all recommended pharmacotherapies and individual and group counseling for all Medicaid enrollees.

The 2008 Public Health Service guideline identifies four combination therapies (i.e., two tobacco-dependence medications taken simultaneously) as being effective in treating tobacco-dependence: (1) nicotine patch and nicotine gum, (2) nicotine patch and nicotine nasal spray, (3) nicotine patch and nicotine inhaler, and (4) nicotine patch and bupropion SR.³ The most commonly covered combination of tobacco-dependence treatments among the Medicaid programs was the nicotine patch and bupropion SR (33 programs), followed by the nicotine patch and nicotine gum (21 programs), the nicotine patch and nicotine inhaler (21 programs), and the nicotine patch and nicotine nasal spray (19 programs).

Fewer Medicaid programs covered counseling than pharmacotherapy; 18 programs covered individual counseling for all Medicaid enrollees, six programs covered only FFS enrollees (with two restricting coverage to pregnant women), one covered MCO enrollees only, and six covered only pregnant women. Eight Medicaid programs covered group counseling for all Medicaid enrollees, three programs covered group counseling for FFS only (with two restricting coverage to pregnant women), two programs covered only MCO enrollees, and five programs covered group counseling for pregnant women only.†

Nationwide, coverage for any tobacco-dependence treatments increased, from 45 programs (including two with coverage only for pregnant women) to 47 programs since 2007, the most recent year for which comparable data were reported.⁶ Nebraska added coverage for tobacco-dependence treatments for FFS enrollees and Alabama added individual counseling for pregnant women. In addition, Arizona and Washington expanded coverage previously limited to pregnant women to include all Medicaid enrollees. Overall, 12 Medicaid programs added or expanded coverage from 2007 to 2009.

Medicaid enrollment options vary considerably across and within states. Some states offer only traditional FFS Medicaid, others enter into contracts with MCOs to provide services to Medicaid enrollees. Because some state programs reported different coverage policies for FFS and MCO enrollees, and for pregnant women, Medicaid recipients within a state might have varying degrees of access to tobacco-dependence treatments. Some states required that all MCO contracts provide an agreed upon level of coverage for tobacco-dependence treatments; other states allow MCOs to determine what coverage they offer. For example, 32 Medicaid programs covered nicotine gum to all enrollees, but nine programs offered coverage for nicotine gum to their FFS population without requirements to provide this coverage in their MCO contracts. In addition, Rhode Island required coverage for nicotine gum in contracts with MCOs, but does not cover this treatment for FFS enrollees. Overall, 16 programs reported coverage for FFS enrollees that differed from that provided for MCO enrollees.

SB McMenamin, PhD, HA Halpin, PhD, M Ingram, Center for Health and Public Policy Studies, Univ of California, Berkeley. A Rosenthal, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

This report updates previously published information on coverage for tobacco-dependence treatments in Medicaid programs⁶ and, for the first time, lists coverage for FFS, MCO, or all enrollees for each tobacco-dependence treatment in each Medicaid program and provides data on combination therapies. Coverage increased in 12 states since 2007, and in 16 states, coverage for FFS enrollees differed from coverage for MCO enrollees.

Public health initiatives and clinical guidelines to reduce tobacco use have called for comprehensive coverage of recommended treatments.^{3 - 4} Most state Medicaid programs fall short of this goal. Coverage varies considerably for specific tobacco-dependence treatments within states and across states. Tobacco-dependence treatments are one of the few clinical preventive services shown to reduce costs.⁷ Insurers that provide adequate access and support for persons seeking to quit smoking can improve cessation rates substantially, with potential for considerable improvement in public health and reduction in medical expenditures.^{7 - 8} In Massachusetts, for example, a mandate for Medicaid coverage of tobacco-dependence cessation treatments was associated with a 26% decline in smoking rates among Medicaid enrollees.⁹

The findings in this report are subject to at least three limitations. First, Medicaid staff members self-report information on their Medicaid programs. Documentation to verify coverage policies was obtained for 94% of programs; where documentation was not available, errors might have occurred. Second, MCO contracts were not available from all programs. If the state informant did not possess a written contract or policy specifying that tobacco-dependence treatments were covered, the response given by the respondent was assumed to be accurate. Finally, many MCOs offer coverage for tobacco-dependence treatments to Medicaid enrollees, although it is not required per contracts with Medicaid. Consequently, reported data might underestimate tobacco-dependence treatment coverage among MCO enrollees.

Recent federal policy is increasing access to smoking cessation treatments. Section 4107 of the Affordable Care Act has required Medicaid programs to cover tobacco-dependence treatments for pregnant women, with no cost-sharing since October 1, 2010.⁵ Section 4106 of the act permits Medicaid programs to cover the A and B level recommendations of the U.S. Preventive Services Task Force, including cessation counseling and all Food and Drug Administration—approved tobacco-dependence treatments. States that offer such benefits and adult vaccination benefits, and prohibit cost sharing on these benefits, will receive a one full percentage point increase in the Medicaid federal medical assistance percentage for expenditures on these services, effective January 1, 2013.^{3 ,5} Currently, only eight Medicaid programs cover all medications and at least one form of counseling for their entire population; the remaining 43 Medicaid programs would need to add coverage for additional tobacco-dependence treatments if they seek to comply with the U.S. Preventive Services Task Force recommendations. Previous research indicates that knowledge of Medicaid coverage for tobacco-dependence treatments among Medicaid-enrolled smokers is very low.¹⁰ To increase the impact of the federal legislation, it is important that Medicaid programs inform their enrollees and providers about changes in coverage for tobacco-dependence treatments and offer these treatments without barriers or limitations. In addition, future monitoring of Medicaid programs should include measurement of usage rates of tobacco-dependence treatments and assessment of any existing barriers to coverage.

Prevalence of smoking is nearly twice as high among Medicaid enrollees than in the general U.S. population, and Healthy People 2010 calls for expanding coverage for tobacco-dependence treatment to Medicaid programs in all 50 states and the District of Columbia.

What is added by this report?

Although 47 (92%) of 51 Medicaid programs offered coverage for some form of tobacco-dependence treatment to Medicaid enrollees, only five states offer coverage of all recommended pharmacotherapies and individual and group counseling for all Medicaid enrollees, and 16 states have coverage policies that are not consistent for fee-for-service and managed-care organization enrollees.

What are the implications for public health practice?

To increase the effectiveness of recommended tobacco-dependence treatments, Medicaid programs should inform their enrollees and providers about coverage changes, offer tobacco-dependence treatments without barriers or limitations, measure treatment usage rates, and assess any remaining barriers to coverage.

*Zyban is a trade name for bupropion. Coverage was assessed separately for Zyban and bupropion because some programs cover one but not the other. Data presented represent coverage for either bupropion or Zyban.

†Two programs covered counseling for pregnant women in FFS only. These two are included under the totals for pregnancy only and for FFS only.