State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2018–2022

Discussion

During 2018–2022, states continued to add coverage of tobacco cessation treatments and to remove treatment access barriers for standard Medicaid enrollees. However, coverage gaps and access barriers remain in many states. Although the number of states with comprehensive coverage increased from 15 in 2018 to 20 in 2022, this increase falls short of the Healthy People 2030 target of all 50 states and DC.^††† In 2022, only three states provided coverage without any barriers. Increasing cessation coverage and decreasing barriers increases access to effective treatments that can increase the likelihood of successful quitting and improve health outcomes for persons who smoke (4).

The increase in the number of states with comprehensive treatment coverage and without barriers is likely related to state legislative actions. For example, Ohio passed legislation in 2020 requiring the state Medicaid program to cover a comprehensive cessation benefit with minimal barriers; Illinois passed similar legislation in 2021.^§§§ These laws not only improve coverage and removed barriers, but also ensure that managed care plans will maintain this level of coverage in the future, even if new carriers are selected via competitive state bidding processes.

Laws like those passed in Ohio and Illinois can also help standardize tobacco cessation benefits across plans within a state. In the absence of such laws, treatment coverage and barriers can vary within a state’s Medicaid program, potentially limiting treatment access. Different Medicaid-managed care plans within a state can set different coverage policies. Consistent comprehensive coverage of tobacco cessation treatments with minimal barriers has the potential to increase standard Medicaid enrollees’ access to treatments and minimize confusion for both enrollees and providers.

Improved cessation treatment coverage observed in this study might also be related to some states^¶¶¶ implementing Medicaid expansion during the study period (6). Many state Medicaid programs provide the same coverage for standard and expansion enrollees (7). Since states are required to provide expansion enrollees with coverage of all cessation treatments, consistency of coverage between standard and expansion plans might result in improvements in coverage for standard enrollees. Medicaid expansion has been shown to support cessation; states that have implemented Medicaid expansion have witnessed an increase in smoking cessation among lower-income adults (8,9). Opportunities remain for all states to improve coverage and increase promotion of available tobacco cessation benefits to encourage and support successful quitting.

This study demonstrates continued progress in decreasing tobacco cessation treatment access barriers for standard Medicaid enrollees. The biggest improvement in barrier removal was for copayments, with a nearly one third increase in the number of states without copayment requirements. One potential contributor to this change was enactment of the Families First Coronavirus Response Act (FFCRA),**** which increased the federal share of Medicaid spending by 6.2% with the requirement that states limit new cost-sharing for Medicaid enrollees. Continued monitoring of treatment access barriers remains important, particularly because the FFCRA maintenance of effort requirement, which limited cost-sharing, ended in 2023.^†††† How this change in policy might affect access barriers for cessation treatments is unknown.

Limitations

The findings in this report are subject to at least two limitations. First, Medicaid-managed care plans can change with little notice and can vary widely between plans, which can make determining up-to-date coverage challenging. Second, information provided by state personnel could not be verified, potentially resulting in data misclassification.

Implications for Public Health Practice

More than one in five adults enrolled in Medicaid smoke cigarettes (1). Increasing comprehensive, barrier-free tobacco cessation insurance coverage for the more than 48 million adults enrolled in Medicaid^§§§§ has the potential to reduce tobacco-related disparities in this population by increasing access to and usage of treatments that help persons quit smoking (4). By providing barrier-free coverage of all evidence-based tobacco cessation treatments, and promoting this coverage to enrollees and providers, state Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures.