State Medicaid Coverage for Tobacco-Dependence Treatments --- United States, 1994--2001

Tobacco use is the leading preventable cause of death in the United States (1). One of the national health objectives for 2010 is to increase insurance coverage of evidence-based treatment for nicotine dependence (i.e., total coverage of behavioral therapies and Food and Drug Administration [FDA]--approved pharmacotherapies) in Medicaid programs from 36 states to all states and the District of Columbia (DC) (objective 27.8) (2). To increase both the use of treatment by smokers attempting to quit and the number of smokers who quit successfully (3,4), the Guide to Community Preventive Services (5) recommends reducing the "out-of-pocket" cost of effective tobacco-dependence treatments (i.e., individual, group, and telephone counseling, and FDA--approved pharmacotherapies) for smokers. The 2000 Public Health Service (PHS) Clinical Practice Guideline supports expanded insurance coverage for tobacco-dependence treatments (6). In 2000, approximately 32 million low-income persons in the United States received their health insurance coverage through the federal-state Medicaid program (7); 11.5 million (36%) of these persons smoked (CDC, unpublished data, 2000). The amount and type of coverage for tobacco-dependence treatment offered by Medicaid has been reported for 1998 and 2000 from state surveys conducted by the Center for Health and Public Policy Studies (CHPPS) at the University of California, Berkeley (8). All states and DC were re-surveyed in 2001 about amount and type of coverage, and level of coverage since 1994. This report summarizes the results of the survey, which indicate that the number of Medicaid programs providing some coverage for tobacco-dependence counseling or medication increased from 34 in 2000 to 36 in 2001, but only one state offered coverage for all the counseling and pharmacotherapy treatments recommended by the 2000 PHS guideline. If the 2010 national health objective is to be achieved, Medicaid coverage for treatment of tobacco dependence should be increased dramatically.

In 2001, state Medicaid program directors were asked to identify staff members who were most knowledgeable about tobacco-dependence treatment coverage and programs; a survey was faxed to the identified staff member in each state. Additional follow-up was conducted through telephone, e-mail, and fax; the response rate was 100%. The survey included 24 questions about coverage of tobacco-dependence treatments, the year coverage was first offered, treatments offered specifically to pregnant women, awareness and use of the 2000 PHS guideline (6), any program requirements related to patient co-payments for or provider coverage of tobacco-dependence treatments, and whether Medicaid recipients were notified of the availability of covered tobacco-dependence treatment. So that survey responses could be validated, all Medicaid programs were asked to submit a written copy of their coverage policies for tobacco-dependence treatments or other related documentation. Of 36 areas with programs that reported offering coverage in 2001, a total of 24 (67%) provided supporting documentation, six (17%) reported that tobacco-dependence treatments were covered under general benefits, and six (17%) did not submit any documentation.

In 2001, a total of 36 (71%) areas reported offering coverage for at least one form of tobacco-dependence treatment (Table 1), compared with 34 areas in 2000 (8); however, coverage status reported previously in 2000 was revised on the basis of additional information obtained in the 2001 survey about the source of financing and the purpose for which a treatment was covered. In 2000, Massachusetts reported coverage for tobacco-dependence treatments; in the 2001 survey, the state clarified that counseling services were covered by the Massachusetts Department of Public Health rather than by the Medicaid program and that Wellbutrin^® was covered only as an antidepressant and not for treatment of tobacco dependence. In the 2000 survey, Utah reported not having any covered treatment; however, in 2001, the state reported having offered coverage for pregnant women since 2000. Of the 36 areas that offered any coverage in 2001, all but one covered pharmacotherapy treatments, including Zyban^® (35 areas), Wellbutrin^® (33), buproprion sustained release (33), nicotine nasal spray (26), nicotine inhaler (26), nicotine patch (25), and nicotine gum (24). Among the 35 areas with Medicaid programs covering any pharmacotherapy treatments, 16 (46%) required some form of patient cost sharing (range: $0.50 to $3.00 per prescription).

In 2001, a total of 10 states offered some form of tobacco-cessation counseling services (Table 1). Utah restricted counseling services to pregnant women only, and Rhode Island offered counseling services but did not provide coverage for any drug treatments.

In 2001, Medicaid program staff in 28 (55%) states reported being aware of the 2000 PHS guideline (Table 2), compared with 20 in 2000 (CHPPS, unpublished data, 2000). A total of 16 (31%) states reported using the 1996 Agency for Health Care Policy and Research guideline or the 2000 PHS guideline to design tobacco-dependence treatment benefits or programs. Ten (20%) states required contracted providers or health plans to implement the brief counseling protocol recommended by the 2000 PHS guideline, six (11%) states required providers or health plans to document tobacco-use status in patients' medical charts, and 12 (24%) states supported tobacco-dependence treatment practices (e.g., by distributing materials on available treatments or self-help kits or by giving providers feedback on their performance in treating tobacco dependence). Twelve (33%) Medicaid programs that provided coverage informed their recipients that tobacco-dependence treatment benefits were available.

Reported by: HA Halpin, PhD, J Ibrahim, PhD, Center for Health and Public Policy Studies, School of Public Health, Univ of California, Berkeley. CT Orleans, PhD, Robert Wood Johnson Foundation, Princeton, New Jersey. AC Rosenthal, MPH, CG Husten, MD, T Pechacek, PhD, Office on Smoking and Health, CDC.

Editorial Note:

The number of Medicaid programs offering any form of tobacco-dependence treatments increased from 2000 to 2001, but coverage for the 2000 PHS guideline--recommended treatments remained low. In 2001, a total of 15 areas offered no coverage for tobacco-dependence treatments, and only Oregon provided coverage for all treatment options recommended by the 2000 PHS guideline (6). In addition, some states that did offer coverage required patients to share the cost, which has been proven to decrease use of treatment (9). Such co-payments might be even more of a barrier for low-income populations. Because decreasing the cost of effective treatments increases successful smoking cessation (5), cost barriers for low-income smokers should be reduced. In addition, because only one third of states that offer benefits inform their beneficiaries of these benefits, Medicaid smokers interested in quitting might not realize they can obtain financial assistance for tobacco-dependence treatment.

The findings in this report are subject to at least three limitations. First, for some states, data are self-reported, and among the 36 states with Medicaid programs that reported offering coverage, six states did not provide documentation of their policies. The absence of a written policy increases the likelihood of reporting errors. Second, these results might differ from other ratings of coverage because of interpretation of unwritten policies. Finally, the data presented in this report are current as of December 2001 and do not reflect coverage decisions made after that date.

Because Medicaid recipients have approximately 50% greater smoking prevalence than the overall U.S. adult population (8), they are disproportionately affected by tobacco-related disease and disability. Substantial action to improve coverage will be needed if the United States is to achieve the national health objective for 2010 of reducing the prevalence of smoking to 12% among adults (i.e., persons aged >18 years) (objective 27.1) (2). To help states implement evidence-based tobacco-dependence treatment and to improve Medicaid service contracts, CDC is collaborating with George Washington University in developing model purchasing specifications (10). These specifications encourage state Medicaid contracts to require that health-care providers and health plans adopt the brief counseling protocol and systems components outlined in the 2000 PHS guideline. States also are encouraged to use their contracts to track the number of Medicaid smokers and the number of smokers who receive advice to quit, brief cessation counseling, and medication. Finally, states are encouraged to cover all recommended pharmacotherapies and counseling under Medicaid and to promote their use actively.

References

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207--12.
2. U.S. Department of Health and Human Services. Healthy people 2010, 2nd ed. With understanding and improving health and objectives for improving health (2 vols). Washington, DC: U.S. Department of Health and Human Services, 2000.
3. Halpin Schauffler H, McMenamin S, Olson K, Boyce-Smith G, Rideout JA, Kamil J. Variations in treatment benefits influence smoking cessation: results of a randomized controlled trial. Tob Control 2001;10:175--80.
4. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost-effectiveness of smoking cessation services under four insurance plans in a health maintenance organization. N Engl J Med 1998;339:673--9.
5. Hopkins DP, Briss PA, Ricard CJ, et al. Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001;20:16S--66S.
6. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, 2000.
7. Kaiser Family Foundation. Medicaid enrollment: Kaiser Commission on Medicaid and the Uninsured. Washington, DC: Kaiser Family Foundation, 2000.
8. CDC. State Medicaid coverage for tobacco-dependence treatments---United States, 1998 and 2000. MMWR 2002;50:979--82.
9. Solanki G, Halpin Schauffler H. Cost-sharing and the utilization of clinical preventive services. Am J Prev Med 1999;17:127--33.
10. George Washington University Medical Center School of Public Health and Health Services. Sample purchasing specifications related to tobacco-use prevention and cessation: a technical assistance document. Available at http://www.gwhealthpolicy.org/newsps/tobacco.

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