According to a new article in the American Journal of Preventive Medicine, the Affordable Care Act (ACA) improved and expanded state Medicaid coverage of effective smoking cessation treatment, although many programs are not fully compliant with the law.
The analysis, which is based on a SHARE-funded study led by Dr. Sara McMenamin (University of California, San Diego), examined data collected from 50 State Medicaid programs and the District of Columbia using a 12-question web-based survey. The survey assessed each program’s smoking-cessation coverage and its compliance with the four sections of the ACA (i.e., Sections 4107, 4106, 2502, and 2001) that address the expansion of Medicaid coverage for smoking-cessation treatments to bring coverage into alignment with recommendations from the U.S. Preventive Services Task Force (USFSTF). The authors also examined benefits language documents from each state as well as state plan amendments.
Key Findings
- Section 4107 of the ACA: Smoking-Cessation Coverage for Pregnant Women
Section 4107 of the ACA requires coverage of smoking-cessation treatments for pregnant women, including all seven forms of pharmacotherapy and individual and group counseling. Sixteen states adding this comprehensive coverage post-ACA, bringing the total number of states offering ACA-compliant smoking-cessation coverage for pregnant women to 28 (i.e., 55% of states). Taken separately, coverage for pharmacotherapy increased from 26 states covering all seven drugs for pregnant women in 2009 to 47 states in 2017. Coverage for smoking-cessation counseling lagged coverage for pharmacotherapy, with coverage for both face-to-face group and individual counseling for pregnant women increasing from 16 states in 2009 to 28 states in 2017. Of note, the four states that offered no coverage for cessation services for pregnant women in 2009 added at least some coverage by 2017, such that all 51 Medicaid programs offered coverage for at least some pharmacotherapy and counseling treatments to pregnant Medicaid enrollees.
- Section 4106 of the ACA: Coverage of USPSTF-Recommended Preventive Services without Cost-Sharing
Section 4106 of the ACA offers a 1% increase in the Federal Medical Assistance Percentage (FMAP) if Medicaid programs fully cover USPSTF-recommended preventive services, including all effective smoking-cessation treatments, and remove cost-sharing. In all, 15 Medicaid programs have submitted a state plan amendment to implement Section 4106, and nine of these report smoking-cessation coverage in alignment with Section 4106. Prior to the ACA, only one Medicaid program provided smoking-cessation coverage in alignment with Section 4106.
- Section 2502 of the ACA: Smoking-Cessation Pharmacotherapy May Not Be Excluded from Medicaid Formularies
Section 2502 of the ACA prohibits states from excluding any FDA-approved pharmacotherapy from their Medicaid formularies. The number of Medicaid programs covering all recommended pharmacotherapy increased from 26 in 2009 to 48 in 2017.
- Section 2001 of the ACA: Coverage of Preventive Services, Including Smoking Cessation, under Medicaid Expansion
Section 2001 of the ACA requires Medicaid programs in expansion states to cover all USPSTF-recommended preventive services, including smoking cessation, without cost-sharing or prior authorization requirements. In all, 23 of the 32 expanded Medicaid programs covered all recommended smoking-cessation treatments for their Medicaid expansion population. However, two programs were not covering all the recommended pharmacotherapy, and nine were not covering both individual and group counseling. Additionally, four still required cost-sharing for their covered treatments, and 21 have prior authorization requirements for some or all of their covered smoking-cessation treatments.
Conclusion
Medicaid programs have made considerable progress in expanding coverage for smoking-cessation treatments for enrollees since the passage of the ACA. However, the four sections of the ACA that address smoking-cessation treatments have not been fully realized, and the authors note that additional guidance and clarification from the Centers for Medicare and Medicaid Services (CMS) may be needed regarding these sections in order to achieve full compliance with the law.
Read the full American Journal of Preventive Medicine article.