1. Purpose: Recommended quality improvements to MaineCare tobacco cessation coverage for inclusion in a risk-based managed
care contract for specific MaineCare populations and services.
Quick Facts and Background Information:
 41.4%i of Maine’s Medicaid/MaineCare recipients smoke. This is more than twice the rate of smoking of Maine’s adult population (17.2%ii),
and well above the national average.iii
o 76%of MaineCare smokers desire to quit smoking. iv
 10.58% of Maine’s Medicaid/MaineCare expenditures, or a total of $216 million, are attributed to tobacco use.v
 Best Practice Guidelines
o In 2007, a legislative directive (Resolve 2007, c. 34) required the Department of Health and Human Services to “undertake a study of
best practice treatment and clinical practice guidelines for tobacco cessation treatment” and to “use the most recent available
clinical practice guidelines of the US Department of Health and Human Services Public Health Services” to design a model for both
public and private insurance coverage of tobacco cessation treatment. Below is one result of study: an outline of a model tobacco
dependence treatment program—
 Screening, identification and intervention for tobacco use by every practice with referral as necessary for further counseling.
 Evidence based pharmacotherapy is readily available to all.
 Pharmacotherapy and counseling are not linked in a payment scheme; one can be reimbursed without the other.
 Cost sharing and deductible are minimal; the duration of treatment reimbursed reflects successful quit patterns.
 Benefits are targeted to those most in need of assistance with quitting such as pregnant smokers and those with behavioral
health problems, such as depression.
 Providers are given adequate reimbursement for counseling.
 Education is conducted about benefits offered and evaluation of treatment provided is conducted on a regular basis.
 Impact of Health Care Reform
o As of October 2010, all Medicaid programs will be required to cover a comprehensive treatment benefit for pregnant women on
Medicaid.
o Tobacco treatment medications have been removed from the list of excludable medications.
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2. o States that cover all preventative services given a grade of ‘A’ or ‘B’ by the US Preventative Services Task force (including tobacco
treatment) with no cost-sharing will begin receiving a one percentage point increase in FMAP for those services starting in 2014.
Item Description Timeline Outcomes Existing Benefit
 Implement mandated  Tobacco screening
agreement with providers  90% of providers will be coverage provided
to identify, document, addressing tobacco use when provided in a
 All new and renewing
assess and address with Medicaid patients physician’s office.
contractors will be
tobacco use with all and will be reporting to
Screenings required to adhere to
patients at every visit. MaineCare screening
this procedure by July
 Offer reimbursements to data associated with
2013.
offices that submit reports tobacco use among their
of compliance with this Medicaid patients.
mandated item.
 Continued coverage of all  NRT gum and patch
 Pharmacotherapy  50% of MaineCare
FDA approved limited to up to 3
barriers, including recipients who smoke
pharmacotherapy months (each)
prior authorization and express a desire to
(prescription and OTC). duration per year.
requirements and quit will utilize at least
 Eliminate copays for any Maybe used in
duration limits will be one form of
and all FDA approved combination with
removed from pharmacotherapy in their
tobacco treatment Bupropion.
Access to MaineCare benefits by attempt to quit tobacco
pharmacotherapy, or  NRT nasal spay
Pharmacotherapy July 2012. by July 2013.
provide copay voucher covered with prior
 Copays and cost  Of the 50% who attempt
program for individuals authorization, if
sharing requirements to quit using
who cannot afford their gum and patch tried
for tobacco treatment pharmacotherapy, 20%
prescriptions. and failed or if
medications will be will successfully have quit
 Remove prior presence of a
eliminated by July by July 2014.
authorization requirement condition that
2012.
for NRT nasal spray and prevents usage of
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3. inhaler. preferred drug or
 Eliminate requirements for interaction with
one treatment in order to another drug and
utilize another (i.e. require preferred drug
patient use patch before exist.
use of inhaler).  NRT inhaler is
 Remove single-time use covered with prior
limit on use of Varenicline authorization, if
(Chantix). gum and patch tried
 Eliminate duration and failed or if
limitations on presence of a
pharmacotherapy and condition that
support for multiple quit prevents usage of
attempts. preferred drug or
interaction with
another drug and
preferred drug
exist.
 NRT lozenge is
covered for
members not able
to tolerate patch or
gum. May be used
in combination or
with Bupropion
tablets for
cessation.
 Varenicline is
covered with prior
authorization with a
lifetime limit of one
use.
 Bupropoin SR 100
and 150mg is
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4. available up to 3
months per year.
 MaineCare requires
$3 copay for all
pharmacotherapy.
 All tobacco
cessation products
require MaineCare
members meet with
the primary care
provider before
pharmacotherapy
can be
administered.
 Provide reimbursements  Expanded  50% Medicaid patients  Individual
for tobacco treatment and reimbursements for who identify themselves counseling available
screening preformed by physicians and as smokers who wish to to members for up
certified tobacco tobacco treatment quit will be referred to to 3
treatment specialists specialists who the Maine Tobacco sessions/appointme
working under qualified provide counseling HelpLine. nts per year.
provider. shall be implemented  50% of Medicaid patients  Individual
 Implement fax services by July 2012. who identify themselves counseling is only a
(and EMR) for providers  All contracted as smokers through the reimbursable
Counseling Services and
referring patients to the practices will begin initial physician screening measure on the
Clinical Reimbursements
Maine Tobacco HelpLine. utilizing the new will receive intermediate inventive payment
 Continue to provide counseling codes for counseling (3-10 for private
reimbursement for physicians and in- minutes). physicians; does not
intensive (>10 minute) office tobacco  30% of Medicaid patients cover TTS-C.
tobacco treatment treatment specialists who identify themselves  Group counseling is
counseling conducted by by July 2013. as smokers through the not covered under
physician, and add  Data related to initial physician screening MaineCare.
reimbursement for utilization of quit will receive intensive
certified tobacco resources will be counseling (>10 minutes).
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5. treatment specialists. obtained by  5% of Medicaid patients
 Provide reimbursements MaineCare and who identify themselves
to physicians and certified reported out by as smokers with a desire
tobacco treatment December 2014. to quit through the initial
specialists for providing physician screening will
group therapy sessions to participate in group
Medicaid patients. tobacco treatment
counseling.
 30% of Medicaid patients
who identify themselves
as smokers through the
initial physician screening
will utilize telephone
counseling, such as that
provided by the Maine
Tobacco HelpLine.
Communication plan of MCOs shall include:
 Promotions directly related to the MaineCare tobacco treatment benefit
o Paid media, such as television ads, radio ads, web banner and other applicable means to reaching target
population
o Consumer materials crafted for low-literacy population.
o Provider education materials to increase awareness and utilization of benefit and referral.
 Education should target both the primary care provider and practice management.
i
BRFSS, 2008.
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6. ii
BRFSS, 2009.
iii
The Medicaid population (18-65) smokes at a rate of 32.6%. National Health Interview Survey, 2007.
iv
BRFSS, 2008.
v
Campaign for Tobacco-Free Kids, 2010.
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