Tobacco Cessation Survey for Medicaid Managed Care Organizations
April2017
The Health and Human Services Commission and Department of State Health Services are collaborating to gainbetter insightsinto tobacco cessation services currently available to Medicaid members.The results ofthe survey are confidential and will be de-identified for general discussion on potential opportunities for improving cessation services.
This survey requires a response from all plans by 4/24/17.
Thank you for completing the survey!
Name of the Person Completing the Survey:
Email address:
Title:
Name of your Health Plan:
Select allMedicaid programs your Health Plan participates in:
STAR
STAR Health
STAR + PLUS
STAR Kids
Dual Demo
Q1: For Medicaid members, does your health plan capturetheir tobacco or other nicotine- containing product use?
No
Yes…By Certification
Yes…By Self-Attest
Yes…By Other (please specify)
Q2: Approximately what percent of your Medicaid members use tobacco or other nicotine-containing products?
0- 24%
25 - 49%
50 - 74%
75 - 100%
Unknown
Q3: Approximately what percent of your Medicaid members are exposed to second-hand smoke?
0- 24%
25 - 49%
50 - 74%
75 - 100%
Unknown
Q4. Does your health plan target certain groups with tobacco cessation information?
Yes
No
If Yes for Q4, select all conditions your health plan targets with tobacco cessation information.
Pregnant women
Allergy / Asthma
Respiratory Disease (COPD)
Diabetes
Cardiovascular Disease
Substance Abuse
Mental Illness
Other (please specify)
Q5. Beyond required benefits for pregnant women, does your health plan offertobacco cessation benefits to other Medicaid members?
Yes
No (If No, skip Q6-Q11 and go to Q12_
Q6. Excluding pregnant women, select all tobacco cessation benefits your health plan offersMedicaid members.
Specific Health Plan Quitline
Referrals to National Quitline
Referrals to Texas Quitline
24/7 Nurse Hotline
Cessation Counseling
Nicotine Replacement Therapy (NRT)
Prescription Cessation Medications
Other (please specify)
Q7.Excluding pregnant women, does your health plan offertobacco cessation telephone counseling for Medicaid members?
Yes
No
If YES for Q7, briefly describe how may calls are allowed per year and who provides the telephone counseling.
Q8.Excluding pregnant women, does your health plan offertobacco cessation in-person counseling sessions for Medicaid members?
Yes
No
If YES for Q8, briefly describe how many sessions are allowed per year and who provides the counseling sessions.
Q9.Does your health plan limit the amount of Nicotine Replacement Therapy (NRT) for Medicaid members (e.g., monthly limit)?
No / YesNRT: Patch / /
NRT: Gum / /
NRT: Lozenges / /
NRT: Other / /
NRT: Other (please specify)
If YES for Q9, briefly describe the quantity limit(s).
Q10. Does your health plan cover simultaneous use of multiple NRT for Medicaid members?
Yes
No
Q11. Does your health plan follow-up with Medicaid members referred to tobacco cessation services to determine if they quit?
Yes
No
If Yes for Q11, what percent of referred Medicaid members quit?
0- 24%
25 - 49%
50 - 74%
75 - 100%
Unknown
Q12.Briefly provide other information you want to share on tobacco cessation services for Medicaid members.