Quitline did not provide NRT in FY2016 – SKIP to Question 13 2 week supply – CONTINUE to Question 10 4 week supply – CONTINUE to Question 10 5 week supply – CONTINUE to Question 10 8 week supply – CONTINUE to Question 10 Other: please specify - CONTINUE to Question 10 *10. Are some quitline participants eligible for a longer supply? NAQC is seeking to generally understand the number of state quitlines that may provide more NRT to certain populations. Yes No Do not know/unsure *11. Did the amount of NRT provided to eligible quitline participants in FY16 decrease at any point in the fiscal year? Yes – CONTINUE to Question 12 No – SKIP to Question 13 Do not know/unsure – SKIP to Question 13 *12. Please indicate why the amount of NRT provided to eligible quitline participants in FY16 decreased (e.g., budget constraints, TIPS campaign). *13. For FY16, please indicate if your state quitline provided any amount of NRT to quitline participants who were enrolled in Medicaid. State quitline did not provide NRT to quitline participants enrolled in Medicaid. –
the relationship between media/promotion expenditures and reach. Outreach is the act of providing quitline and referral information to specific populations or groups through activities such as face-to-face meetings or training sessions with key organizations that provide services to the targeted population. While the Quitline Outreach budget may be separate from the activities of the Quitline Media/Promotions budget for some quitlines, we are asking that Quitline Media/Promotions & Outreach be reported as one. Definition of OTHER QUILINE SPECIFIC ITEMS & ACTIVITIES BUDGET Other Quitline Specific Items & Activities budget funding includes any other quitline-specific items/categories which do not fit into the quitline budget categories specified in the table. Definition of TOTAL QUITLINE BUDGET: TOTAL Quitline Budget should be the sum of budget categories listed in a – e of the table. FY2016 Quitline Budget Total Dollar Amount for FY2016 25a. Quitline Services $ 25b. Quitline Medications $ 25c. Quitline Evaluation $ 25d. Quitline Media/Promotions & Outreach $ 25e. Other Quitline specific items or activities $ 25f. TOTAL Quitline Budget (sum of a – e) $ *26. For FY16, please indicate on the table below all Government funding sources that supported your TOTAL FY16 Quitline Budget (as reported in Question 25, Row f). GOVERNMENT FUNDING SOURCES Did your state’s quitline receive funding from any of these sources in FY16? 26a. CDC yes no 26b. State funds (includes general fund, tobacco taxes) yes no 26c. State Medicaid Funds that are allocated directly from the state Medicaid budget to the state tobacco control program. These funds are separate from Medicaid Match/FFP yes no 26d. Federal Financial Participation (FFP, i.e., Medicaid Match) for quitline administrative expenditures for Medicaid beneficiaries, secured through the CMS quitline guideline that are drawn down by the state Medicaid agency and paid to the state tobacco control program specifically for the quitline budget. yes no
26e. Master Settlement Agreement (MSA) or Tobacco Settlement yes no 26f. Research grant from government sources (e.g., NIH, CDC) yes no 26g. public funders yes no S *27. Please indicate in the below the types of “cost-sharing” the state quitline has in place and which organization holds the “cost-sharing” agreements. Definition of COST-SHARING: Cost-sharing is defined as a financial agreement where one entity (i.e., a health plan or employer) pays for or reimburses for quitline services (i.e., counseling and/or cessation medications) provided to their members or employees by the state quitline or the state quitline’s service provider. The financial agreement could also pay for an enhanced level cessation services above those offered by the state quitline. Type of Organization Is there a cost-sharing agreement with the organization for quitline services? Which organization holds the cost-sharing agreement for the state quitline? 27a. Private Health Plans Yes No Do not know State tobacco control program or state health department State Quitline Service Provider Foundation Other Do not know 27b. Private Employer Groups Yes State tobacco control program or state health department