State Medicaid Coverage for Tobacco-Dependence Treatments—United States, 2006

February 8, 2008 / Vol. 57 / No. 5

MMWR Highlights

• Tobacco use costs the United States $193 billion each year in health care costs and lost productivity.
• An estimated 14% of Medicaid costs are attributable to tobacco use.
• In 2006, approximately 35% of Medicaid recipients smoked cigarettes.
• Tobacco-dependence treatments (including FDA-approved pharmacotherapy and individual, group, and telephone counseling) are highly cost-effective, even cost-saving in some populations.

Extent of Coverage

• Eight states still provide no Medicaid coverage for tobacco-dependence treatments, only seven states covered all FDA-approved medications and at least one form of counseling for all Medicaid recipients, and only one state (Oregon) covers all treatments recommended by federal clinical practice guideline.
• While free counseling services may be available to Medicaid enrollees through state quitlines and some of these provide pharmacotherapy to Medicaid enrollees, many quitlines do not have the capacity to provide comprehensive services. Medicaid partnerships with state quitlines to provide treatment services for this high-risk population can ensure that Medicaid recipients receive the treatments that will maximize their chances of quitting.
• Thirty-nine (76.5%) Medicaid programs offer coverage for at least one form of tobacco-dependence treatment for their entire Medicaid population. Of these, all cover some pharmacotherapy. Four states reported that they offer at least one form of tobacco-dependence treatment coverage for pregnant women only.
• Seventeen states cover some form of tobacco-cessation counseling for their entire Medicaid population, and another 10 states cover counseling services for pregnant women only.
• Of the 17 states that cover group counseling, 10 cover counseling for all Medicaid enrollees, while seven cover group counseling for pregnant women only.
• Of the 25 states that cover individual counseling, 14 cover the entire population, while 11 cover it for pregnant women only.
• The three states that cover telephone counseling cover it for the entire Medicaid population.
• From 2005 to 2006, overall coverage increased slightly for existing tobacco-dependence treatments—with two states (Alaska and Massachusetts) adding coverage, one state (Delaware) expanding its coverage to include the nicotine lozenge, and one state (Oklahoma) expanding its coverage to include individual counseling.
• Varenicline, approved by the FDA in 2006, was added as a covered benefit in 32 states.
• No state added coverage for telephone counseling in 2006.
• In three states (California, New York, and Rhode Island), tobacco-dependence treatments are covered by Medicaid managed care organizations (MCOs) but are not covered under fee-for-service Medicaid.

Limitations/Barriers to Coverage

• Many Medicaid programs impose limitations on tobacco-dependence treatment coverage, which is inconsistent with federal clinical practice guidelines (i.e., the use of co-payments, requiring prior authorization to obtain coverage, limits on duration of treatment, requiring a patient to try one form of therapy before accessing another ["stepped care"], or coverage for only one type of tobacco-dependence treatment at a time).
• Only New Mexico has medication coverage policies for the entire Medicaid population consistent with current guideline recommendations to reduce barriers to tobacco-dependence treatments.
• The most common limitation imposed by Medicaid programs is requiring co-payments for tobacco-dependence treatments.
• Among the 43 programs that cover tobacco-dependence treatments, 14 require co-payments for all covered tobacco-dependence treatments (medications and counseling) and 17 require co-payments for specific tobacco-dependence treatments (including 11 states that require co-payments for pharmacotherapy but not counseling, three states require co-payments for brand tobacco-dependence treatments but not generic drugs, and three states require co-payments for some medications and not others).
• Among the 40 programs covering any generic drugs for tobacco-dependence treatment, 26 (65%) require co-payments for generic tobacco-dependence treatments.
• Of the 40 programs covering any brand name medications for tobacco-dependence treatment, 30 (75%) require co-payments.
• Of the 27 programs covering counseling, five (19%) required co-payments.
• Prior authorization for tobacco-dependence treatments is required by 20 states, with six states requiring prior authorization for all tobacco-dependence treatments and 14 states requiring it for selected treatments.
• Twenty-two Medicaid programs have limitations on the duration of treatment for medications (median: 12 weeks) and 21 have limitations on the number of treatment courses per year (median: 1 course). Four programs (Colorado, Louisiana, Montana, and North Dakota) apply these limits to a "lifetime benefit."
• Seven state Medicaid programs require "stepped care," which is the use of a specific tobacco-dependence treatment before any other treatments are covered
• Eleven states require enrollees to participate in counseling services to be eligible for pharmacotherapy coverage, even though two of these programs do not cover counseling.
• Nine states report that Medicaid will only pay for one smoking cessation pharmacotherapy at a time.