To quit smoking is not easy, and health policies that support those motivated to quit can help tilt the balance from setback to success. Under the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative, state teams of Medicaid and public health officials are leveraging cross-agency partnerships to: (1) remove barriers that impede access to tobacco cessation treatments; and (2) promote increased use of treatment benefits covered under Medicaid. Of the nine states participating in the first phase of the 6|18 Initiative, seven sought to reduce tobacco use in their Medicaid populations. With Robert Wood Johnson Foundation support, the Center for Health Care Strategies (CHCS) is providing these states with targeted technical assistance to advance their prevention goals and will soon launch work with a new set of 6|18 participants — including states as well as commercial insurers in a separate group.

While coverage of certain preventive and wellness services — including tobacco cessation services — is mandated under the Affordable Care Act, states have significant flexibility in how they design these benefits for Medicaid beneficiaries. In many states, Medicaid tobacco cessation benefits include copays, prior authorization requirements, and quantity limits on medications or counseling services — features that may reduce access to care. Studies show that successful smoking cessation typically involves multiple quit attempts and a multi-pronged approach (i.e., some combination of cessation medication and counseling), so policies that make accessing cessation services more difficult can jeopardize an individual’s chance of success. On the flip side, states with robust and easily accessible cessation services have reduced smoking rates and created a positive return on investment.

The 6|18 Initiative brings together Medicaid and public health agencies to work collaboratively on shared prevention goals, leveraging each agency’s unique yet complementary roles. For example, Medicaid’s authority over benefit design enables teams to pursue significant statewide policy changes, while public health’s expertise in designing and implementing public education campaigns helps states advertise new or existing cessation services. Below are examples of these collaborative, cross-agency efforts within a subset of states participating in the 6|18 Initiative.

Eliminating Barriers to Tobacco Cessation Benefits

Massachusetts is seeking to remove co-payments for Medicaid tobacco cessation medications as well as co-payments for opioid addiction medications and overdose treatment. The Medicaid-public health team began by conducting an analysis to identify the potential financial impact of eliminating these co-pays. It then developed proposed regulations regarding the co-pay removal and solicited public feedback. Upon potential approval of the regulation (anticipated later this year), the team will submit State Plan Amendments to update the copayment structure and obtain a one percent Federal Medical Assistance Percentage (FMAP) increase, which states are eligible for after removing cost sharing for recommended preventive services. In addition, Massachusetts has removed all remaining prior authorization for tobacco cessation medications.

South Carolina identified inconsistent coverage of tobacco cessation services across its five Medicaid managed care organizations (MCOs) as a barrier to providers in promoting benefits and to members in seeking treatment. In response, the state is working to enhance and standardize benefits across all MCOs. The team first surveyed the MCOs to understand the scope of services available and conducted an actuarial analysis to model the potential costs and savings associated with removing co-pays and prior authorization requirements for tobacco cessation services, as well as offering a more robust counseling benefit. After receiving buy-in from MCO leadership, the state is moving forward with the proposed policy changes, which are slated to take effect this year.

Increasing Use of Cessation Services

Minnesota’s 6|18 team surveyed its Medicaid MCOs regarding their cessation treatment coverage and promotional activities, then used the survey data to query MCOs that did not appear to be in compliance with state policies. That process resulted in improved and more uniform cessation treatment coverage. It also helped the Minnesota team better understand the types of cessation treatment benefits that eligible smokers could expect from Medicaid and enhanced its ability to communicate information to beneficiaries about treatment options. The Minnesota Department of Health (MDH) and ClearWay Minnesota also expanded the outreach of their “You can Afford to Quit Smoking. Free help through Medical Assistance” campaign. It engaged MDH Tobacco Free Community grantees, ClearWay Minnesota grantees, and QUITPLAN Services to promote free Medicaid benefits to populations disproportionately impacted by the harms of tobacco.

New York worked to reduce Medicaid member tobacco use through both policy changes (e.g., expanding access to cessation services for individuals with behavioral health and substance use disorder diagnoses) and targeted promotional campaigns aimed at both providers and members. Using a clear and consistent message — “Smoking is an addiction. Medicaid and your health care provider can help” — New York highlighted the state’s Medicaid tobacco cessation benefits on billboards and in television and digital ads. New York has historically seen an increase in the use of covered services following the roll-out of member-focused campaigns, and received anecdotal feedback from providers that the provider-targeted ads motivated them to initiate conversations with patients about smoking cessation.

Colorado introduced legislation to enhance pharmacists’ scope of work, giving them authority to prescribe tobacco cessation medications with the aim of increasing access. Colorado also sought to increase awareness of the cessation services available to Medicaid members. Using the message “Medicaid has you covered,” Colorado created print materials to advertise Medicaid tobacco cessation services. The state also ran digital ads on Facebook, using Google analytics to geo-target counties that were identified as having high — 20 percent of the population or higher — tobacco use prevalence.

Looking Forward

Thanks to the fruitful Medicaid-public health partnerships being fostered under the 6|18 Initiative, states are helping Medicaid beneficiaries move one step closer to being tobacco-free. Examples from these states demonstrate the unique skills and expertise that Medicaid and public health officials each bring to a collaborative effort — with Medicaid providing leadership on payment and benefit changes, and public health contributing on-the-ground knowledge of how to improve access and utilization. As the CDC’s 6|18 Initiative introduces a new set of states, these lessons and the progress made during this past year will prove invaluable.

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