Case Study: The Effect of Expanding Cessation Coverage—

The Massachusetts Medicaid Cessation Benefit

States can design and implement tobacco cessation benefits through 

Medicaid that are accessible, affordable, and that cover all evidence-based 

cessation treatments including counseling and medications. 

The Massachusetts experience highlighted below shows that providing a broad cessation benefit through Medicaid can 

increase use of evidence-based cessation treatments, reduce smoking rates, improve health outcomes, and decrease 

medical costs over a short time period. The MassHealth cessation benefit had a major effect on all of these outcomes even 

though it was made available to a vulnerable, underserved, low-income population traditionally viewed as hard to reach. 

The lack of comprehensive Medicaid cessation coverage in most states represents a major missed opportunity to 

improve health outcomes in a vulnerable population while reducing health care costs.

The Health Burden and Costs of Tobacco Use

Smoking is the leading preventable cause of death in the 

United States. It kills about 480,000 Americans each year and 

causes more than 16 million people to suffer from disease 

and disability in the United States.1 Annually, smoking costs 

the nation at least $130 billion in direct medical costs and 

more than $150 billion in lost productivity.1 While smoking 

rates among the general population in the United States have 

declined in recent years,2

 they remain substantially higher 

among Medicaid beneficiaries2 and smoking-related diseases 

are a major driver of Medicaid costs.3

Recommended Interventions 

In the United States, about 70% of smokers want to quit and 

about 50% make a quit attempt each year.4,5 However, less 

than 10% succeed, in part because of under use of proven 

cessation treatments.4,5 Seven FDA-approved cessation 

medications along with individual, group, and telephone 

counseling have been shown to be effective in helping 

smokers quit.4 While medication and counseling are each 

effective when used alone, they are more effective when used 

together.4 In addition to being clinically effective, cessation 

treatments are also extremely cost-effective relative to other 

commonly used, routinely reimbursed medical interventions 

such as hypertension treatment and mammography.4

Comprehensive coverage—meaning a combination of 

recommended medications and counseling that is covered 

by insurance with no cost-sharing required—increases the 

number of smokers who use these treatments, attempt to 

quit, and succeed in quitting.4

Tobacco Cessation in Massachusetts

Smoking costs the Massachusetts Medicaid program, 

MassHealth, $1 billion annually in excess health care costs.6

Adults with lower incomes (below $25,000 annually) are 

almost three times more likely to smoke than adults with 

higher incomes ($75,000 or more annually).6

 The 2006 MA 

Health Reform law specified that pregnant women and 

women with children younger than age 3 should be covered 

for smoking cessation benefits through Medicaid.7

 The two 

lead agencies, the Department of Public Health (DPH) and 

Medicaid, ultimately recommended a more comprehensive 

benefit that provided cessation coverage to all Medicaid 

beneficiaries, which was less complicated to administer 

than providing a benefit to only a subset of the Medicaid 

population that would require eligibility checks.8 After several 

benefit design meetings and multiple cost projection analyses, 

this expanded benefit was recommended to and approved by 

both agency heads.8

The final benefit provides coverage of all FDA-approved 

cessation medications and individual and group counseling.9,10

Only seven states cover all FDA-recommended cessation 

treatments for all Medicaid enrollees18 even though a recent study 

found that Medicaid recipients who lived in states with generous 

tobacco cessation coverage had the highest successful quit rates.17

1
2

Tobacco Cessation in Massachusetts, cont’d

MassHealth and DPH officials met on a weekly basis for 

more than a year to develop the components of the program 

along with its processes and expected outcomes.11 At the 

program’s inception, enrollees could obtain up to two, 90-day 

regimens of smoking cessation medications per year (90-

days per quit attempt), which included the nicotine patch, 

gum, lozenge, bupropion, and varenicline.10 The nicotine 

inhaler and nicotine nasal spray could be obtained with 

prior authorization. Medications could also be combined; 

for example, the patch and gum or the bupropion and patch. 

Medications were prescribed by a Medicaid provider for a 

nominal co-payment fee ($1-$3).10

Up to 16 counseling sessions were available per year in the 

form of individual or group counseling, and more could 

be provided with pre-authorization.10 To provide greater 

accessibility to tobacco cessation counseling, a wide range 

of providers were authorized to provide these services 

including physicians, nurse practitioners, nurse midwives, 

registered nurses, physicians’ assistants, and qualified 

tobacco cessation counselors (defined as someone who has 

completed at least 8 hours of training in tobacco cessation 

services from an accredited institute of higher education).12

Independent nurse practitioners and independent nurse 

midwives could provide tobacco cessation counseling 

directly without being supervised by a physician.12 If 

face-to-face counseling was unavailable, providers are 

encouraged to refer patients to the MA quit line and the 

QuitWorks telephone-based program operated by the 

Massachusetts DPH.12

The DPH also initiated 

a broad publicity and 

outreach campaign 

in conjunction with 

MassHealth to achieve 

a high usage rate 

among providers and 

consumers.9,10 For 

providers, this included 

the development of 

fact sheets, detailed 

Frequently Asked Question [FAQs] with rate and billing 

codes, a pharmacotherapy pocket guide, and new intake 

and assessment protocols that were widely disseminated 

to health care systems and facilities.13 Consumers were 

targeted with direct mailings, radio ads, transit ads,*

 and 

regular communications were sent to provider groups 

including medical associations and subspecialty groups.13

DPH officials were trained and given access to MassHealth 

data to track benefit use and to provide feedback and 

special recognition to providers who were regularly 

referring patients to the program.11 

From fiscal year (FY) 2007 to 2009, approximately 

75,000 smokers (40% of MassHealth smokers) 

participated in the program.10 MassHealth spent about $20 

million on medications and counseling, and the DPH spent 

$558,500 on promotion and outreach.14 

The program resulted in the following outcomes:

• Reduced smoking prevalence: 

Using the Massachusetts Behavioral Risk Factor 

Surveillance System (BRFSS) data, smoking prevalence 

was examined in the MassHealth population from 

1999–2008. The smoking rate among MassHealth 

beneficiaries decreased from 38% in 2006 to 

28% in 2008, representing a 26% decline in the 

first 2.5 years.10

• Reduced hospitalizations: 

Using MassHealth claims data, DPH researchers 

compared the probability of hospitalization before 

and after use of the pharmacotherapy benefit among 

MassHealth beneficiaries. Researchers examined 

diagnoses by looking at cardiovascular group codes, 

respiratory group codes, and other conditions. There 

was a 46% decrease in hospitalizations for heart 

attacks and a 49% decrease in hospitalizations 

for other acute heart disease diagnoses among 

users of the pharmacotherapy benefit. There 

were no significant decreases in hospitalizations for 

respiratory and other diagnoses.15 

• Return on investment: 

Using program costs and savings attributable to the 

reduction of cardiovascular admissions among Medicaid 

beneficiaries, researchers calculated the return on 

investment (ROI) associated with the tobacco cessation 

benefit. During FY 2007–2009, annual program costs—

including pharmacotherapy, counseling, and outreach— 

totaled about $183 per participant, while annual hospital 

savings were estimated at $571 per participant. Every 

$1 in program costs was associated with $3.12 

in medical savings for cardiovascular conditions 

alone, for a $2.12 ROI to the Medicaid 

program for every dollar spent.14

Since the benefit was instituted, certain changes have been 

made to ensure its continued availability and sustainability. 

The initial co-pay of $1–$3, which was the standard 

price for a prescription benefit through MassHealth, was 

increased to $3.65 in 2011 to reflect current charges.16

Over-the-counter medications, such as the patch and gum, 

are no longer restricted to a 90-day supply and can now be 

provided to support as many quit attempts as the consumer 

makes annually.8

*

A new FDA-approved cessation medication, varenicline (Chantix), was released by Pfizer and heavily promoted in Massachusetts at the same time that the campaign occurred. 

Other pharmaceutical manufacturers also promoted cessation medications during this period. These promotional efforts were not linked to the public health campaign.
3

Summary 

Several key features of the Massachusetts 

Tobacco Cessation Program contributed to 

its success.

• Passage of the state health reform law: 

The passage of the Massachusetts health reform law 

acted as a catalyst for the expansion of tobacco cessation 

coverage to all MassHealth beneficiaries.

• Built on existing infrastructure 

and partnerships: 

MassHealth and the DPH established a close partnership 

that predated the benefit, laying the groundwork for 

close collaboration in implementing and promoting 

the new cessation coverage. Existing referral and quit 

line infrastructure was used to expand the benefit to 

MassHealth participants. 

• Reduced barriers to utilization: 

To maximize access to cessation treatments, counseling 

or prior authorization was not required to receive most 

medications; billing for smoking cessation counseling was 

allowed on the same day as a medical visit for another 

purpose; and there was a nominal copayment fee.

• Provided broad coverage: 

The benefit covered a range of evidence-based cessation 

treatments, including all FDA-approved medications and 

individual and group counseling.

• Engaged providers and consumers: 

A major effort was made to promote the benefit to 

Medicaid providers and beneficiaries through tailored 

communication channels. 

• Documented impact: 

Systems were put in place in advance to monitor and 

document benefit use and its effect on smoking rates, 

health outcomes, and medical costs in the state’s 

Medicaid population.

The passage of the Patient Protection and 

Affordable Care Act represents a major 

opportunity to offer evidence-based tobacco 

cessation benefits to all smokers, regardless of 

their type of health insurance. 

The Act requires non-grandfathered health insurance plans 

to cover without cost sharing all preventive services that have 

received “A” or “B” ratings from the US Preventive Services 

Task Force (USPSTF), which includes the following tobacco 

cessation services: 

• Screening for tobacco use

• Tobacco cessation counseling and all FDA-approved 

tobacco cessation medications †

The Affordable Care Act also requires state Medicaid 

programs to provide comprehensive smoking cessation 

coverage to pregnant women and bars these programs 

from excluding FDA-approved cessation medications 

from coverage.20

State officials should be well-versed in their state’s essential 

health benefit, as it will govern which tobacco cessation 

services are covered by small group and individual plans, 

plans in state marketplaces, and Medicaid expansion plans.18

While insurers are allowed to charge tobacco users higher 

premiums—up to a 50% higher rate than they charge to 

non-tobacco users—smokers in plans in the group market 

can avoid the higher premiums if they participate in a 

cessation program. States also have the legal authority to 

prohibit this higher rate or place a lower ceiling on the 

permitted premium increase.19,20

State public health officials can be valuable 

partners in smoking cessation efforts. 

Public health departments can develop and target 

educational campaigns to consumers and providers 

using social and traditional media, printed and online 

materials, and other outreach approaches conducted by 

staff or contractors. In addition, they can provide specific, 

evidence-based recommendations on how to make 

cessation programs effective and analyze data to track 

cessation use and health outcomes. State public health and 

health care leaders are strongly encouraged to examine 

opportunities for structuring evidence-based tobacco 

cessation programs for maximum effect.

† Specific guidance on cessation services required under ACA is available at http://www.dol.gov/ebsa/faqs/faq-aca19.html under Q5. 
4

References

1. US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon

General. Atlanta, GA:US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. http://www.cdc.gov/tobacco/data_statistics/

sgr/50th-anniversary/index.htm. Accessed January 21, 2014.

2. Pleis JR, Lucas JW. Summary health statistics for US adults: National Health Interview Survey, 2007. Vital Health Statistics. 2009;10:240.

3. Armour BS, Finkelstein EA, Fiebelkorn IC. State-level Medicaid expenditures attributable to smoking. Prev Chronic Dis. 2009;6 (3): 1-10.

4. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical practice guideline.

Rockville, MD: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2008.

http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html#Clinic.

Accessed January 21, 2014.

5. Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001–010. MMWR. 2011;60(44):1513-19.

6. Massachusetts Department of Public Health. A Profile of Health among Massachusetts Adults, 2011 Web site.

http://www.mass.gov/eohhs/docs/dph/behavioral-risk/report-2011.pdf Accessed October 25, 2013.

7. Massachusetts Department of Public Health. MassHealth Smoking Cessation Benefit, Briefing Notes Web site.

http://www.mass.gov/eohhs/docs/dph/tobacco-control/masshealth-smoke-cessation-benefit.doc Accessed January 24, 2014

8. Landau, A. (2014 February) Personal communication

9. Partnership for Prevention. Policy Brief. Saving Money: The Massachusetts Tobacco Cessation Medicaid Benefit.2011. http://www.prevent.

org/data/images/roi%20policy%20paper_a.pdf Accessed January 30, 2014.

10. Land T, Warner D, Paskowsky M, Cammaerts A, Wetherell L, et al. Medicaid coverage for tobacco dependence treatments in

Massachusetts and associated decreases in smoking prevalence. PLoS ONE. 2010;5:e9770.doi:10.1371/journal.pone.0009770.

11. Land, T. (2014 January) Personal communication.

12. Massachusetts Department of Public Health. MassHealth Tobacco Cessation Benefits Web site. http://www.mass.gov/eohhs/gov/

newsroom/masshealth/providers/masshealth-tobacco-cessation-benefits.html Accessed February 5, 2014.

13. Massachusetts Department of Public Health. MassHealth Factsheet for Providers. http://www.mass.gov/eohhs/docs/masshealth/provli

brary/fact-sheet-providers.pdf Accessed February 5, 2014.

14. Richard P, West K, Ku L . The return on investment of a Medicaid Tobacco Cessation Program in Massachusetts. PLoS ONE. 2012;

7(1):e29665. doi:10.1371/journal.pone.0029665.

15. Land T, Rigotti N, Levy D, Paskowsky M, Warner D, Paskowsky M, et al. A longitudinal study of Medicaid coverage for tobacco dependence

treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular diseases. PLoS Med 2010; 7(12): e10000375.

doi:10.1371/journal.pmed. 100375.

16. Commonwealth of Massachusetts. Executive Office of Health and Human Services Web site. http://www.mass.gov/eohhs/docs/

masshealth/poster-copay-pharmacy.pdf. Accessed February 20, 2014.

17. Greene J, Sacks RM, McMenamin SB. “The impact of tobacco dependence treatment coverage and co-payments in medicaid.” American

Journal of Preventive Medicine. 2014; 46(4):331-336.

18. Singleterry J, Jump Z, Lancet E, Babb S, MacNeil A, Zhang L. State Medicaid coverage for tobacco cessation treatments and barriers to

coverage—United States, 2008–2014. MMWR. 2014;63(12);264-269.

19. Kofman M, Dunton JD, Senkewicz MB. The Implementation of Tobacco Cessation Coverage Under the Affordable Care Act: understanding

How Private Health Insurance Policies Cover Tobacco Cessation Treatments. Georgetown University, Health Policy Institute; 2012.

20. American Lung Association. “Implementation of the Affordable Care Act: Next Steps for Tobacco Control Web site.:

http://www.lung.org/stop-smoking/tobacco-control-advocacy/reports-resources/tobacco-cessation-affordable-care-act/aca-factsheetsresources.html. Accessed February 20,2014.

For more information on this program or evidence-based tobacco cessation interventions, please contact 

• MassHealth—Roger Snow, Deputy Medical

Director, Medical Policy

• Massachusetts Tobacco Cessation and Prevention

Program—Anna Landau, Director, Tobacco

Cessation Programs

• CDC Office on Smoking and Health –

Stephen Babb and Ann Malarcher

• CDC Division of Population Health – Karen Voetsch

CS 249343A