State Medicaid Coverage for Tobacco-Dependence Treatments --- United States, 2005

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In 2005, approximately 41 million persons in the United States had health insurance coverage through Medicaid, a federally and state-funded health-care program, managed at the state level, for persons with limited incomes (1). An estimated 29% of adult Medicaid recipients were current smokers in 2004 (2). The 2000 Public Health Service (PHS) clinical practice guideline recommends that insurance coverage be provided for tobacco-dependence treatments, including both medication (i.e., bupropion hydrochloride or nicotine patch, gum, inhaler, or nasal spray) and counseling (i.e., individual, group, or telephone) (3). A national health objective for 2010 is to increase insurance coverage of evidence-based treatments for tobacco dependence among all 51 Medicaid programs (objective 27-8) (4). The type of coverage for tobacco-dependence treatments offered by Medicaid has been reported since 1998, and most recently for 2003, from state surveys conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley (5,6). All states and the District of Columbia (collectively referred to as states in this report) were resurveyed in 2005 regarding types of coverage and limitations in coverage since 1994. This report summarizes the results of that survey, which indicated that as of December 31, 2005, 1) 38 state Medicaid programs covered some tobacco-dependence treatment (i.e., counseling or medication) for all Medicaid recipients; 2) four states offered coverage only for pregnant women; 3) one state (Oregon) offered coverage for all medication and counseling treatments recommended by the 2000 PHS guideline; and 4) seven states (including Oregon) covered all recommended medications and at least one form of counseling. If the 2010 national health objective is to be achieved, states should offer or increase Medicaid coverage for treatment of tobacco dependence (4).

In 2005, state Medicaid program directors were asked to identify the staff member who was 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 by 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 only to pregnant women, and any program requirements related to patient copayments or other limitations related to tobacco-dependence treatments. So that survey responses could be validated, all state Medicaid programs were asked to submit a written copy of coverage policies for tobacco-dependence treatments or other documentation. Of 42 states reporting Medicaid coverage in 2005, a total of 41 (98%) provided some supporting documentation: 16 (38%) provided detailed treatment documentation matching survey responses, 14 (33%) provided partial treatment information (i.e., documentation for medication but not counseling), eight (19%) provided general treatment information (i.e., documentation that addressed coverage for tobacco-dependence treatments but did not specify which type), and three (7%) provided documentation conflicting with survey responses that were later followed up for inclusion in this report.

In 2005, a total of 38 (75%) state Medicaid programs reported offering coverage for at least one form of tobacco-dependence treatment (i.e., medication or counseling) for all Medicaid beneficiaries (Table 1). Four additional states reported that they covered at least one form of tobacco-dependence treatment but only for pregnant women. Of the 38 states that offered at least one form of coverage to all Medicaid beneficiaries in 2005, all covered some type of medication treatment, including generic bupropion hydrochloride or Zyban^®* (36 states), nicotine nasal sprays (28 states), nicotine inhalers (28 states), nicotine patches (33 states), and nicotine gum (31 states). During 2003--2005, two states (Rhode Island and South Carolina) added medication coverage, and three others (Arkansas, North Carolina, and Utah) expanded existing medication coverage. Some decreases in coverage also occurred; New Jersey eliminated seven previously covered tobacco-dependence treatments, and two states (Maine and Maryland) eliminated one form of medication coverage.

In 2005, a total of 14 states offered some form of tobacco-cessation counseling services for their entire Medicaid population (Table 1), and 12 additional states offered counseling services only for pregnant women. During 2003--2005, one state (Arkansas) added coverage for counseling of all Medicaid beneficiaries, one state (New Mexico) added coverage for counseling of pregnant women, and two states (North Dakota and Wisconsin) expanded existing counseling coverage.

Among the 38 state Medicaid programs covering any medication treatment for all Medicaid beneficiaries, 25 (66%) required some form of patient cost sharing (range: $0.50 to $5.00 per prescription) (Table 2). States were least likely to require copayments for nicotine gum (55%) and most likely to require copayments for nicotine nasal spray (71%). The median copayment among Medicaid programs was similar for all tobacco-dependence treatments, ranging from $2.50 to $3.00. Similarly, the median weeks of treatment covered (12 weeks) did not vary by type of medication, and little variation was observed in the median number of treatment courses covered per year (1--1.5 courses). In addition, certain states reported that they put no limits on coverage for these medications. States were least likely to offer unlimited coverage for the nicotine-replacement patch (27%), which is available over the counter, and most likely to offer unlimited coverage for Zyban (39%), which is available only with a prescription. Data collected on limitations in coverage indicate that for nicotine-replacement--therapy products that are available over the counter that were assessed by this study (i.e., patch and gum), all but one state require a prescription.

Almost one fourth of Medicaid programs that cover tobacco-dependence treatments indicated that medication coverage depended on enrollment in a behavior-modification program or participation in smoking-cessation counseling. Of the nine states that required behavioral counseling as a condition of covering medication, four covered the required counseling. In addition, approximately one third reported that their Medicaid program paid for one smoking-cessation medication at a time. Furthermore, one third of states covering medication indicated that tobacco-dependence treatments counted toward a general prescription limit.

Reported by: HA Halpin, PhD, SB McMenamin, PhD, CA Cella, Center for Health and Public Policy Studies, School of Public Health, Univ of California, Berkeley. CG Husten, MD, Abby Rosenthal, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Despite publication of tobacco-use treatment guidelines in 1996 and updates in 2000 documenting that use of nicotine-replacement therapy, the nonnicotine medication Zyban, or counseling all can double cessation rates (3), coverage of tobacco-dependence treatments by Medicaid remains low and is increasing slowly. In 2005, one state, Oregon, covered all medications approved by FDA and all three forms of counseling recommended by PHS clinical practice guideline. Nine states offered no Medicaid coverage for tobacco-dependence treatments, and four states offered coverage for at least one treatment option (i.e., medication or counseling) but only to pregnant women.

The number of state Medicaid programs offering any medication coverage increased by one during 2003--2005, and the number of states that expanded coverage of medications also increased by one during the same period. Coverage for counseling increased by two states, and expansion of counseling coverage increased by two states. However, 66% of states that offered coverage required patients to share the cost of treatment. In addition, almost one fourth of state Medicaid programs that cover tobacco-dependence treatments indicated that medication coverage was dependent on enrollment in a behavior-modification program or participation in smoking-cessation counseling, another barrier to using treatment (particularly because counseling was covered by only 44% of these states). Previous studies also have indicated that most programs that offer tobacco-dependence treatment benefits do not inform their beneficiaries of those benefits (7), creating additional barriers to successful smoking cessation.

Because decreasing the cost of effective treatments increases smoking cessation (8), cost barriers for smokers should be reduced. In a study that assessed the impact and cost-effectiveness of recommended preventive services, smoking-cessation treatment was among the top-ranked clinical preventive services (with childhood immunization and discussing aspirin chemoprophylaxis for adults at risk for cardiovascular disease) (9); these three treatments were determined to save health-care costs. Because the adverse health effects of smoking result in 14% of Medicaid costs (10), implementation of tobacco-dependence treatments should be a priority.

The findings in this report are subject to at least two limitations. First, although all but one state provided some supporting documentation, only 38% provided complete documentation of the treatments covered. This lack of confirmatory documentation increases the likelihood of reporting errors. Second, these results might differ from other ratings of coverage because of differing interpretations of unwritten policies.

Because smoking prevalence among Medicaid recipients is approximately 39% greater than the prevalence in the overall U.S. adult population (2), Medicaid recipients are disproportionately affected by tobacco-related diseases and disabilities. Substantial measures to improve coverage will be needed to achieve the national health objective for 2010 of reducing the prevalence of smoking to 12% among persons aged >18 years (objective 27-1a) (4). To help states implement evidence-based tobacco-dependence treatment and to improve Medicaid service contracts, CDC collaborated with George Washington University (Washington, DC) to develop sample specifications for the purchase of tobacco-use prevention and cessation services (information available at http://www.gwumc.edu/sphhs/healthpolicy/chsrp/newsps/tobacco). As a result, Medicaid programs are encouraged to cover all PHS-recommended treatments, cover two courses of treatment per year, eliminate or minimize copayments, and promote tobacco-dependence coverage benefits to Medicaid recipients to reduce the adverse health effects in this population.

References

* The drug bupropion hydrochloride is sold in its generic form and under the brand names Wellbutrin^® (with an indication for depression) and Zyban (with an indication for smoking cessation). Although generic bupropion, Wellbutrin, and Zyban contain the same active ingredient (bupropion hydrochloride), only generic bupropion and Zyban are approved by the Food and Drug Administration (FDA) specifically for smoking-cessation treatment. Therefore, although some state Medicaid programs cover Wellbutrin for smoking cessation, only coverage of generic bupropion and Zyban for smoking cessation are discussed in this report.

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