Responsibility for Treating Tobacco Dependence in Health Clinics Serving Medicaid Enrollees

The American Journal of Accountable CareDecember 2022
Volume 10
Issue 4

This article describes the implementation of Medicaid smoking cessation guidance in a large, urban federally qualified health center to examine how state-level provisions translated into clinic-level policies.


Objectives: In 2016, the California Department of Health Care Services released All Plan Letter (APL) 16-014 to Medicaid managed care plans to issue guidance on the provision of mandated tobacco cessation services. This case study presents implementation of APL 16-014 in a large, urban federally qualified health center (FQHC) to examine how managed care plans’ adoption of different provisions of the APL translated to clinic-level policies.

Study Design: This descriptive study used both qualitative and quantitative methods to assess implementation of APL 16-014.

Methods: In 2021, a questionnaire was distributed to key clinic stakeholders to assess how closely the FQHC followed provisions in the APL. In-depth interviews were also conducted with providers to gather their opinions and experiences on tobacco cessation services offered at the FQHC. Formulary coverage for tobacco cessation medications was collected for all contracting managed care plans.

Results: There was no language in contracts between FQHCs and managed care plans regarding tobacco cessation. Despite this, the FQHC followed 8 of 13 clinic-level APL provisions completely, 2 of 13 partially, and 3 of 13 not at all. The FQHC had the highest implementation rate in provisions related to tobacco use assessment and lowest in provider training and reporting data to managed care plans.

Conclusions: The APL has a long list of requirements, but Medicaid oversight and enforcement is poor. Thus, 5 years after the APL was released, clinic contracts still do not reflect the requirements in the APL. Medicaid programs outside California should consider how requirements for managed care plans and contracting providers are structured and include some mechanism for assessing tobacco use treatment as part of routine auditing processes.

Am J Accountable Care. 2022;10(4):29-34.


Although the California Tobacco Control program has had great success in implementing state-level policies to reduce tobacco use, the percentage of Medicaid (ie, Medi-Cal) enrollees who smoke cigarettes remains disproportionately high.1,2 About 41.5% of adult smokers in California—approximately 1.3 million beneficiaries—rely on Medi-Cal for health insurance, which puts a large financial burden on Medi-Cal programs to treat tobacco-related illness and disease.3 To address this, in 2016, the California Department of Health Care Services (DHCS) sent All Plan Letter (APL) 16-014 to its 25 contracted managed care plans (MCPs) to detail specific MCP requirements related to provision of comprehensive tobacco cessation services to Medi-Cal enrollees.4

Included in the APL are requirements to provide cessation medications and counseling, train providers, and institute a data collection system to monitor tobacco use and treatment.4 Previous research on the implementation of the APL at the MCP level found that only 1 of 25 MCPs adopted all requirements of the APL.5 There is currently no research on the impact that the APL has had at the clinic or provider level. This case study will describe how the 13 provider-related APL requirements have been implemented at the clinic level, using a large, urban federally qualified health center (FQHC) primary care clinic in San Diego as a case study. This FQHC serves more than 20,000 tobacco users across 22 primary care clinics, of whom two-thirds are enrolled in Medi-Cal. The results from this case study will inform implementation of state Medicaid tobacco cessation initiatives both within and outside California and will identify barriers to providing tobacco cessation treatment to Medicaid enrollees.


Data to assess clinic-level implementation of the APL were collected via 3 methods: a questionnaire distributed to key FQHC clinic stakeholders, interviews conducted with FQHC providers, and examination of MCP drug formularies.

All methods used in the collection of human subjects data were performed in accordance with Title 45, Part 46 of the Code of Federal Regulations, and were approved by the University of California, San Diego Human Research Protections Program institutional review board (approval #201170). Informed consent was received from all participants.

Clinic Questionnaire

From May to June 2021, a 13-item questionnaire was distributed to assess FQHC implementation of required APL requirements and other voluntary smoking cessation practices (Table 16). It was administered to a diverse group of knowledgeable clinic stakeholders within the FQHC with access to the FQHC’s MCP contracts. Questions related to billing and data reporting were directed to a billing supervisor and a clinical outcomes coordinator, whereas questions related to clinical flow were directed to a primary care provider, a study coordinator who managed the FQHC’s tobacco cessation services, and a former medical assistant. Data were collected through email and video calls. The questionnaire was considered complete when all parties agreed on FQHC responses.

Provider Interviews

Researchers conducted semistructured, in-depth interviews with the FQHC’s health care providers via Zoom (n = 6). The providers were purposively sampled to reflect diversity based on clinic location and patient base.7 All interviews were recorded, transcribed, and subsequently cleaned and verified. Rapid qualitative analysis methods were employed to conduct purposeful data reduction. Informed by a priori measures and emergent ideas, data matrices were constructed to determine major themes across interviews.8 In addition, themes and direct quotes related to the 13 APL clinic-level provisions were compiled.

MCP Pharmacy Formulary Review

Formulary coverage for tobacco cessation medications was also gathered for all 6 Medi-Cal MCPs operating in the county. This information was obtained by downloading each MCP formulary from its respective website. For each covered drug, data were extracted related to requirements for prior authorization (PA), existence of quantity limits, dosages covered, step therapy requirements, and coverage for generic and brand versions.

Data Analysis

For each item on the APL that related to MCP requirements for contracted providers, the clinic questionnaire was utilized to gather information related to clinic-level operations. In addition, the qualitative data from the provider interviews were reviewed for each APL-related topic, and thematic summaries and direct quotes were pulled out to illustrate specific activities related to APL requirements. The MCP formularies were reviewed for inconsistencies in required coverage for tobacco cessation medications that could affect clinical practice.


Table 16 presents the findings of the clinic questionnaire that looked at the FQHC’s alignment with the APL. None of the 13 APL requirements related to providers were found in the 6 MCP contracts with the FQHC. Despite this, the FQHC still followed 8 of the 13 requirements completely and 2 of the 13 requirements partially (ie, addressed some component of the provision). Three of the 13 APL requirements were not followed at all.


MCPs do not have any mechanisms in place that require the FQHC to assess tobacco use status even though it is required in the APL. Despite this, the FQHC followed 3 of 5 APL requirements related to tobacco use assessment and partially followed the other 2. Many of these processes were already included in the FQHC’s electronic health record (EHR) system, which was described by an FQHC provider as a “pretty intensive EHR that is very motivated toward monitoring substance [use] and other preventive measures.”

Counseling Interventions

The FQHC contracts with the MCPs did not include any requirements for the FQHC to provide smoking cessation counseling. Despite this, the FQHC followed 4 of the 5 APL requirements related to counseling. Even though resources and flows existed for referring patients to counseling, some providers indicated a lack of familiarity with available cessation classes. Some providers reported that the counseling referrals to group classes or the California quitline is problematic because they do not get feedback on patient participation and experience.

Medication Interventions

Medication coverage is determined by each individual MCP’s formulary (Table 2). Across the 6 MCP formularies, 4 covered all 7 cessation medications, whereas 2 indicated coverage for 5 of the 7 required tobacco cessation medications and were missing coverage for nicotine inhaler and nasal spray. All the MCP formularies followed other APL requirements, including having no restrictions on a 90-day treatment regimen and not requiring beneficiaries to receive tobacco cessation counseling as a condition of receiving coverage for cessation medications.

APL requirements allow for the use of PA, as long as 1 of the 7 cessation medications is available without a PA. The providers interviewed at the FQHC had mixed opinions on insurance coverage for tobacco cessation medications. Some had no problems with insurance, whereas others described tobacco cessation PAs as “ridiculous” or “onerous,” especially when multiple PAs had to be completed for a single product. One provider speculated that some patients are “probably falling through the cracks” because “they’re not getting their medications filled, but [providers]…don’t find out about it right away.”

Provider Training

The MCPs did not have any requirements for the FQHC to provide tobacco cessation training to its health care providers, and the FQHC did not offer any sort of provider training. Providers at the FQHC reported that getting more information on cessation options or training on cessation techniques is a top priority. Along with this, physicians also expressed interest in learning more about cessation techniques such as motivational interviewing. Providers also mentioned needing details on the California quitline, FQHC cessation classes, and insurance coverage for cessation.

Data Monitoring

MCPs did not have any requirements that the FQHC collect or report tobacco-related data. The FQHC had an identification system built into its EHR system, but data were not reported to MCPs. Instead, they were reported to the Health Resources and Services Administration (HRSA).9


This case study found that the items specified by DHCS in the APL are not appearing in MCP contracts with providers. Despite this, the FQHC engaged in 8 of the 13 tobacco cessation APL provisions. Even in a large FQHC with leadership dedicated to addressing tobacco use among its patient population, without MCP contractual requirements, some provisions went unaddressed.

In terms of assessment of tobacco use initially, annually, and at every visit, the FQHC had a tobacco assessment system already built into its EHR without any contract requirements from the MCPs. The extent to which providers can make progress on addressing tobacco use among their patient population will depend on their ability to monitor tobacco use and exposure in their patient populations. Given the number of competing demands facing primary care providers, building tobacco use prompts into the EHR is the best way to ensure that clinical practice guidelines related to assessment of tobacco use are followed.10

Counseling interventions as specified by the APL were for the most part available in the FQHC, but physicians had reservations about referring patients to the FQHC’s cessation courses and the California quitline due to a lack of knowledge about these resources. This implies that although these interventions can be required, they may be underutilized if providers are not adequately informed about them. In addition, developing mechanisms for providing feedback to providers regarding patient utilization of these resources could be key.

Tobacco cessation treatments involving medications came with their own set of challenges. Although the coverage on MCP formularies seen in Table 2 mostly follow the APL requirements, variations exist among MCPs in terms of covering all required medications and PA limitations. This heterogeneity could explain why some providers found prescribing medications to be an onerous process. In 2022, California removed pharmacy benefits from the Medicaid MCPs and created a comprehensive pharmacy benefit administered by DHCS.11 This new system should standardize pharmacy benefits and reduce uncertainty on the part of prescribing providers.

The APL requires MCPs to deliver provider training related to tobacco cessation interventions. The FQHC did not report receiving any training from any of the 6 MCPs it contracts with. Provider training emphasizing what is included in cessation classes and the California quitline could encourage more physicians to refer patients to these services. Provider training about variations in insurance coverage and clarifications regarding PAs may also help physicians navigate patients’ insurance more effectively.

The APL requires that MCPs collect and report on 3 tobacco use measures that are part of the Consumer Assessment of Healthcare Providers and Systems survey.12 The FQHC indicated that it is not required to report any patient data to the MCPs and the only reporting of tobacco measures is to HRSA for an annual Uniform Data Systems report. Although the FQHC sent tobacco use data to HRSA, the lack of data sent to MCPs indicates that the MCPs are doing little to hold their contracted providers accountable for their tobacco cessation efforts. Given the lack of contractual language and auditing to ensure compliance, it is not surprising that the APL has not been fully implemented.


The work presented here is a result of a case study; therefore, it is unclear to what extent these results are generalizable to other FQHCs or clinics. In addition, as this is a large FQHC, it is possible that it is better equipped to implement the APL provisions; thus, this could represent an upper bound of tobacco cessation services being offered in other FQHCs. Although these data were collected in 2021, 5 years after issuance of the APL, this lag should have allowed sufficient time for APL implementation.


In San Diego, Medi-Cal enrollees have an option of 6 different MCPs, and contracting providers are faced with navigating 6 different tobacco cessation benefit designs and services for their Medi-Cal patients who use tobacco. Although some of the MCPs may provide robust benefits and services in alignment with APL requirements, others may not adhere to the requirements. In addition, whereas some FQHCs, like the one highlighted in this case study, may opt to provide tobacco cessation services in alignment with the APL, others may not, thus creating even more heterogeneity in services offered to Medicaid beneficiaries. As FQHCs provide care for 1 in 3 low-income Americans and as individuals with lower incomes use tobacco at higher rates, an important opportunity exists to address tobacco use among patients in FQHCs. Medicaid programs outside California should consider how requirements for MCPs and contracting providers are structured and include some mechanism for assessing tobacco use treatment as part of routine auditing processes. Finally, MCPs should ensure that they have specific language in their provider contracts that require providers to follow the state-level provisions in ways that MCPs can enforce.

Author Affiliations: Laura Rodriguez Research Institute, Family Health Centers of San Diego (AT, JL, PM), San Diego, CA; Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego (KCB, DS, SWY, SBM), La Jolla, CA.

Source of Funding: This work was funded by the Tobacco-Related Disease Research Program under grant numbers 28IR-0056 and T31CR2231. The study sponsor had no role in study design, data collection, analysis, interpretation, writing the report, or submission for publication.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JL, DS, PM); acquisition of data (AT, JL, PM); analysis and interpretation of data (KCB, JL, SWY); drafting of the manuscript (AT, KCB, SBM); critical revision of the manuscript for important intellectual content (KCB, JL, DS, SWY); statistical analysis (AT); provision of study materials or patients (JL, PM); obtaining funding (JL, DS, SBM); administrative, technical, or logistic support (DS, SWY, PM); and supervision (SBM).

Send Correspondence to: Sara B. McMenamin, PhD, MPH, University of California, San Diego, 9500 Gilman Dr #0725, La Jolla, CA 92093-0725. Email:


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6. Staying Healthy Assessment. California Department of Health Care Services. Accessed July 12, 2021.

7. Feldstein AC, Glasgow RE. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34(4):228-243. doi:10.1016/S1553-7250(08)34030-6

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9. Preventive care and screening: tobacco use: screening and cessation intervention. eCQI Resource Center. Accessed July 16, 2021.

10. 2008 PHS Guideline Update Panel, Liaisons, and Staff. Treating tobacco use and dependence: 2008 update U.S. Public Health Service Clinical Practice Guideline executive summary. Respir Care. 2008;53(9):1217-1222.

11. Newsom G. Executive order N-01-19. California Executive Department. January 7, 2019. Accessed November 1, 2022.

12. Medical assistance with smoking and tobacco cessation: findings from a 2014-2015 nationwide survey of adult Medicaid beneficiaries. Medicaid. July 2017. Accessed May 27, 2021.

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