North Carolina: Improving Access to Medicaid Tobacco Cessation Benefits
State Spotlight | November 2022
The Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative highlights CDC and partners targeting six common and costly health conditions with 18 proven interventions. The following example from North Carolina showcases some of the strategies used to address one condition under the 6|18 Initiative. These profiles are stories reported by the state officials based on their work within the 6|18 Initiative.
North Carolina Key Facts
- State population: 4 million
- Medicaid population: 6 million
- Medicaid enrollees in primary care case management: 83 percent
- Medicaid enrollees who smoke: 27 percent
Through their participation in the Centers for Disease Control and Prevention’s (CDC) 6|18 Initiative, the North Carolina Department of Health and Human Services, which houses both the Division of Health Benefits (Medicaid) and the Division of Public Health (public health), have collaborated since 2017 to streamline and increase coverage of tobacco dependence treatment and services; remove barriers to covered tobacco dependence treatments; promote use of covered treatment benefits for people who use tobacco; and address health disparities by improving access to tobacco use and dependence treatment for people with behavioral health conditions.
North Carolina participated in two rounds of the CDC’s 6|18 Initiative through which CDC provided formal technical assistance and collaboration opportunities through their partners. This spotlight highlights accomplishments from North Carolina’s Medicaid and Public Health partnership to promote tobacco cessation in the state through their participation in the 6|18 Initiative and beyond.
In 2017, North Carolina participated in the 6|18 Initiative while implementing its decision to transition from fee-for-service Medicaid to managed care. The transition to managed care presented an opportunity for North Carolina’s Medicaid program to partner with public health on population health improvement efforts, stretch beyond standard billing and coding, and consider available Medicaid levers, such as requiring tobacco-free care environments, to impact population health. The 6|18 roadmap helped the agencies collaborate to implement proven tobacco cessation interventions, including incorporating tobacco cessation Quitline services into Medicaid managed care quality improvement planning and Medicaid managed care organization (MCO) contracts.
The NC Public Health, Division of Mental Health/Developmental Disabilities/Substance Abuse Services, and Medicaid team worked together to increase access, eliminate barriers, and promote evidence-based tobacco cessation treatments. In the past, this team successfully implemented tobacco- free campuses and integrated tobacco cessation treatment at all of NC’s state-operated behavioral health facilities. This past success laid the groundwork to support NC’s goal of incorporating into the transition to Medicaid managed care the integration of behavioral health care and medical services, including tobacco prevention and cessation services. More specifically, at the time of its participation in round two of the CDC’s 6|18 initiative, NC was focused on the behavioral health care plans that cover individuals with severe mental illness, substance use disorders, intellectual and developmental disabilities, and traumatic brain injuries, with the goal of fully integrating medical and behavioral health care services for their members by December 1, 2022.
The partnership between the NC Medicaid and Public Health agencies and their participation in the 6|18 initiative generated the leadership and support necessary to require provider organizations serving Medicaid members to implement a tobacco-free grounds policy while also providing evidence-based tobacco treatment at facilities and provider locations. This effort advanced health equity for Medicaid enrollees with behavioral health conditions who often do not have access to cessation treatments despite having a higher smoking prevalence rate than individuals without a behavioral health condition.
North Carolina’s 6|18 Accomplishments
- Required MCO contracts to use the state tobacco quit line, QuitlineNC, simplifying the process for providers and patients.
- Required Medicaid providers to have a tobacco-free campus policy by December 1, 2022. While all Medicaid beneficiaries can benefit from this policy change, this removes a barrier experienced disproportionately by people with behavioral health conditions. For example, all 127 acute care hospitals in NC have tobacco-free campus policies. About one third of North Carolina mental health and substance use treatment programs listed in the SAMHSA provider locator database had smoke-free campuses when this policy was announced via Medicaid bulletin in 2021.
- Expanded access to nicotine replacement therapy (NRT) from the QuitlineNC for Medicaid callers.
- Revised MCO contracts to require submission of annual quality measures on tobacco cessation efforts; submission of a yearly Tobacco Cessation Plan; and care management training on tobacco exposure, brief intervention, and standard of care services. Each MCO is required to: include promotion of QuitlineNC and promotion of tobacco-free campuses; ensure tobacco use screening and treatment (counseling and medications) at all inpatient, facilities, and community settings; ensure tobacco use (including e-cigarettes) is assessed and addressed in all relevant care needs screening, comprehensive assessment, and care plan; increase use of smoking cessation CPT codes, as appropriate; use of incentives for members and providers; and offer provider training on the Smoking Cessation CPT codes.
- The Quitline vendor adopted a new behavioral health protocol that addresses the challenges of quitting tobacco use for people with mental health or substance use diagnoses. Under the new protocol, people with schizophrenia or bipolar disorders are automatically asked if they would like to be enrolled in a tobacco cessation treatment program.
- Added a policy to allow eligible providers to offer tobacco cessation counseling through telehealth services to Medicaid and State-funded beneficiaries for the duration of the NC state of emergency declaration
6|18 Project Activities
North Carolina’s Medicaid and public health agencies partnered to implement a prevention project focused on:
- Increasing access to evidence-based tobacco dependence treatments, including individual, group, and telephone counseling and FDA-approved NRT medications — in accordance with the 2008 Public Health Service Clinical Practice Guidelines.
- Removing barriers that impede access to covered tobacco dependence treatments, such as cost-sharing and prior
- Promoting increased utilization of covered treatment benefits by tobacco users.
- Reducing health disparities among individuals with behavioral health conditions by improving access to tobacco dependence treatments
Specific activities undertaken by the North Carolina 6|18 team include:
Under the transition to managed care, Medicaid and public health explored reimbursement for tobacco dependence treatment for evidence-based individual and group counseling and the seven FDA-approved tobacco cessation medications using integrated providers in medical home settings and telephonic counseling through QuitlineNC. North Carolina created a requirement to increase evidence-based individual counseling, Quitline, and medications as a part of services paid for by MCOs. To support tobacco dependence treatment, NC requires that most providers offer Medicaid-covered services in tobacco-free facilities. Finally, North Carolina continues to work on expanding access to tobacco use treatment counseling. NC Medicaid only reimburses physicians and advanced practice providers for brief tobacco use treatment interventions (CPT codes 99406/94407). Behavioral health professionals cannot be reimbursed for brief counseling interventions. There is no reimbursement for any health care provider or allied health professional to offer more intensive individual or group counseling sessions to help patients quit.
North Carolina sought to remove barriers to some nicotine replacement therapy and counseling, namely: co-pays, prior authorization requirements, and step therapy. One strategy involved leveraging successes from other states in the southern region to inform changes within North Carolina as well. For example, Kentucky removed many barriers for Medicaid enrollees in 2017, such as changes to the insurance coverage for tobacco cessation within it managed care organization contracts. South Carolina also removed barriers to NRT and related services, effective July 2017.
In 2021, the NC General Assembly, passed legislation which enables residents to receive NRT benefits more easily in their communities. The standing order, authorized by the State Health Director, went into effect March 24th, 2022 and allows immunizing pharmacists to dispense, deliver, or administer NRT. Medicaid requires a prescription to cover over-the-counter nicotine replacement therapy and this legislation was intended to reduce the barrier of having to go to a physician to receive the necessary prescription. Historically, North Carolina employed a standing order with a two-week supply of NRT from the QuitlineNC for Medicaid-enrolled callers. The updated standing order allows an immunizing pharmacist to prescribe up to 12 weeks of combination NRT, which can be picked up at a pharmacy. Medicaid beneficiaries can now obtain an NRT prescription and greater supply directly at the pharmacy from immunizing pharmacists.
The North Carolina Medicaid-Public Health partnership also worked to ensure Medicaid support of services provided to enrollees through QuitlineNC. Public-private partnerships, which include Medicaid partnership, have allowed the Division of Public Health to leverage state allocated dollars from the General Assembly to provide more funding directed to QuitlineNC tailored programs and more intensive services for the uninsured and underinsured. North Carolina increased services to the uninsured by adding eight weeks of combination NRT with the quit coaching. Medicare recipients, who are underinsured for over-the-counter cessation medications, can now receive eight weeks of combination NRT. This is an increase from two weeks. In addition, North Carolina added behavioral health and American Indian tailored programs to QuitlineNC.
North Carolina’s Medicaid and Public Health agencies collaborated to pursue funding for a widespread health communications campaign to promote QuitlineNC. The goal was to air a compelling testimonial media campaign when CDC Tips from Former Smokers campaign was off-air.
Additionally, to expand awareness of tobacco treatment within North Carolina’s health and behavioral health systems, the NC team partnered with Duke-University of North Carolina Certified Tobacco Treatment Specialist Training to train clinicians and health system leaders in evidence-based measures to reduce tobacco use. This resulted in the state placing an ad on standard of care for tobacco treatment with the NC Medical Journal and NC Board of Nursing’s The Bulletin.
North Carolina Medicaid educated providers by updating and expanding documentation and billing tools to ensure providers know how to appropriately use screening and diagnostic treatment codes for services to treat tobacco dependence. During 2021, language was added to the Medicaid Managed Care Request for Proposals (RFPs) to strengthen and make all tobacco use treatment and policy requirements uniform. After the state selected the MCOs that demonstrated in their proposals that they could adhere to the treatment and policy requirements, North Carolina provided training on screening and treatment in tobacco-free environments to the MCOs.
The team used the 6|18 Initiative’s framework to come together to reduce tobacco attributable health disparities among Medicaid beneficiaries with behavioral health conditions. A key activity was requiring Medicaid managed care plans’ contracted medical and behavioral health providers to have tobacco-free campuses by December 1, 2022. Retail pharmacies as well as intermediate care facilities and residential supports for people with intellectual/developmental disabilities or traumatic brain injuries (IDD/TBI) were not included in this requirement. This tobacco-free policy was accomplished by including this requirement in the RFP for Medicaid MCOs. Under the new provision of the contracts, all of North Carolina’s MCOs, including those that specifically serve Medicaid beneficiaries with more severe behavioral health diagnoses are required to submit tobacco cessation plans detailing how they will increase the utilitization of tobacco use and dependence treatment and counseling in all settings. The NC team jointly developed and launched a website to assist Medicaid-covered service providers in their efforts to become tobacco-free, including content such as sample tobacco-free policies, information on integrating treatment, FAQs, testimonials, resources, training opportunities, and much more at BreatheEasyNC.org.
This publication was supported by the Centers for Disease Control and Prevention (CDC) contract #47QRAA20D001M, awarded to the National Opinion Research Center (NORC) in partnership with the Center for Health Care Strategies (CHCS). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
CDC would like to thank Joyce L. Swetlick, M.P.H., Director of Tobacco Cessation, Division of Public Health, Tobacco Prevention and Control Branch, North Carolina Department of Health and Human Services, Stephanie Gans LCAS, MSW, NCTTP, Tobacco Treatment Specialist, Division of Public Health, Tobacco Prevention & Control Branch, North Carolina Department of Health and Human Services, Sally Herndon, MPH, Head, Tobacco Prevention and Control Branch, Division of Public Health, North Carolina Department of Health and Human Services, NORC and CHCS for their significant contributions to the 6|18 series of profiles with public health innovators across the United States. Please contact 618@chcs.org with any questions.