FAQs for Medi-Cal Community Health Worker Services – General Information
The following Frequently Asked Questions (FAQs) provide additional guidance and clarification to Medi-Cal members and providers regarding Community Health Worker (CHW) services.
Información general
1. What is a CHW?
CHWs are trusted, trained, unlicensed health professionals who play a vital role in enhancing the health and well-being of Medi-Cal members. CHWs help members who may face challenges, such as cultural or language barriers in communicating with health care providers, by connecting the member with the services they need. CHWs are known by a variety of titles, including promotores, community health representatives, navigators, violence prevention professionals, substance use navigators, and behavioral health navigators, among other titles.
2. What types of services may CHWs provide to a Medi-Cal member?
Los TCS pueden prestar los siguientes servicios:
- Salud education to promote the Medi-Cal member’s health or address barriers to health care, including providing information or instruction on health topics. Health education may include coaching and goal-setting to improve a member’s ability to self-manage their health condition.
- Health navigation to help Medi-Cal members access health care, understand the health care system, engage in their own care, connect to community resources necessary to promote their health and/or address barriers, including medical translation/interpretation or transportation services, supports to address unmet social determinants of health (SDOH) needs affecting the member’s diagnosis, treatment, and overall health, such as food, housing, utilities, or transportation (sometimes referred to as community health integration services). Under health navigation, CHWs may also provide the following:
- Serve as a cultural liaison or help develop or draft a plan of care or treatment plan, which must be reviewed and approved by a licensed provider.
- Outreach and resource coordination to encourage and facilitate use of appropriate preventive services.
- Help a member identify and/or select a primary care provider that meets their individual needs.
- Help a member to initially enroll or maintain enrollment in Medi-Cal (including support with obtaining necessary documentation relative to enrollment) as well as other government or assistance programs (such as CalWORKs or CalFRESH, among others) which are related to improving their health.
- Screening y assessment that assist Medi-Cal members to connect with appropriate services to improve their health.
- Individual support or advocacy that help Medi-Cal members in preventing the onset or exacerbation of a health condition and to help prevent injury or violence.
CHWs may also provide violence prevention services, which are evidence-based, trauma-informed, and culturally responsive preventative services, provided by qualified individuals to reduce the incidence of violent injury or reinjury, trauma, and related harms, and to support recovery, stabilization, and improved health outcomes.
3. How do I receive CHW services?
A licensed provider first determines that a Medi-Cal member would benefit from CHW services and recommends CHW services. The licensed provider could be a physician, dentist, behavioral health provider, nurse, midwife, or another licensed provider.
For example, a licensed providers may determine a Medi-Cal member could benefit from CHW services if a Medi-Cal member who has one or more chronic health conditions (including behavioral health) or exposure to community or domestic violence and trauma, is at risk for a chronic health condition or environmental health exposure, faces barriers meeting their health or health-related social needs, and/or who would benefit from preventive services, would be eligible for CHW services.
To help increase access to care and reduce barriers for Medi-Cal members DHCS issued a statewide standing recommendation that allows all Medi-Cal members who meet the defined eligibility criteria for receiving CHW services would benefit from CHW services. This recommendation fulfills the federal requirements in section 440.130(c) of title 42 of the Code of Federal Regulations for a physician or other licensed practitioner of the health arts acting within their scope of practice to provide a written recommendation for preventive services. In addition, the statewide standing recommendation authorizes supervising providers to bill for CHW services with CPT codes 98960 through 98962 up to the stated frequency limits in Medi-Cal policy (i.e., 4.0 units (2.0 hours) per day). However, it is not applicable to and does not allow supervising providers to bill using HCPCS codes G0019 and G0022 due to the additional Medi-Cal policy requirements for billing.
4. Who is eligible to receive violence preventive services?
When recommended by a licensed provider, CHW violence preventive services are available to Medi-Cal members, when any of the following circumstances are meet:
- El miembro de Medi-Cal ha resultado herido violentamente como resultado de la violencia comunitaria.
- A licensed provider determined the Medi-Cal member is at significant risk of experiencing violent injury due to community violence.
- El miembro de Medi-Cal ha experimentado una exposición crónica a la violencia comunitaria.
CHWs may also provide services to Medi-Cal members experiencing intimate partner or domestic violence.
5. What services may not be provided by a CHW?
CHWs provide non-clinical services and supports to Medi-Cal members. As a result, Medi-Cal does not reimburse for the following services when rendered by a CHW:
- Clinical case management/care management that requires a license
- cuidado de niños
- Chore services, including shopping and cooking
- Servicios de acompañante
- Servicios de empleo
- Helping a member enroll in government programs or insurance that is not related to improving their health as part of a care plan or treatment plan
- Delivery of medication, medical equipment, or medical supply
- Personal care services/homemaker services
- Respite care
- Services that duplicate another covered Medi-Cal service already being provided to a member
- Socialización
- transporte
- Servicios proporcionados a personas no inscritas en Medi-Cal, excepto como se indicó anteriormente
- Servicios que requieren una licencia
CHW services do not include Peer Support Services as covered under the Drug Medi-Cal, Drug Medi-Cal Organized Delivery System, and Specialty Mental Health Services programs. CHW services are distinct and separate from Peer Support Services.
6. What services may CHWs provide under health navigation
Under health navigation, CHWs can help Medi-Cal members:
- Access health care, including finding appropriate providers and securing appointments
- Understand the health care system and engage in the Medi-Cal member’s own care.
- Connect to community resources that support health and reduce barriers, for example medical interpretation, transportation, housing, utilities, and food assistance
- Serve as a cultural liaison and assist a licensed provider in creating a plan of care or treatment plan, as part of the health care team. A CHW may also draft a plan of care or treatment plan identifying CHW intervention services, which must be reviewed and approved by a licensed provider
- Conduct outreach and resource coordination to encourage and facilitate the use of appropriate preventative services
- Select a primary care provider that meets the member’s individual needs
- Assist members to enroll or maintain enrollment in Medi-Cal, including support with obtaining necessary documentation relative to enrollment, as well as other government or assistance programs, such as CalWORKs or CalFresh, etc., which are connected to improving the member’s health goals and plan of care
7. Can you provide an example of how a CHW might provide health navigation services to a Medi-Cal member?
CHW meets Jane at a local community clinic and explains she may be eligible for health care services through Medi-Cal, as well as potentially CalWORKs and/or CalFresh. During the meeting, the CHW helps Jane conduct a needs assessment to identify potential Medi-Cal eligibility by looking at Jane’s individual circumstances, including, but not limited to, income and household size. After identifying that Jane likely meets Medi-Cal eligibility criteria, the CHW assists Jane with gathering necessary documentation, including, but not limited to, identity documentation (e.g., driver’s license or photo ID, Social Security card, a copy of immigration documentation), and income documentation (e.g., recent pay stubs, a copy of paid benefits stubs, etc.). The CHW then assists Jane with completing her application online and uploading the required documents into the secure portal. The CHW could then help Jane prepare for local county office follow-up, which for CalWORKs and CalFresh could include an in-person or phone interview. Lastly, the CHW would periodically follow up with the assigned caseworker at Jane’s local county office to monitor eligibility determination status and, if needed, assist Jane with any missing documentation.
8. If a Medi-Cal member is receiving Enhanced Care Management (ECM) services provided by a Medi-Cal managed care plan under CalAIM, can they also receive CHW services?
CHW services can be provided before ECM begins, after ECM ends, or if the member is ineligible for or declines ECM. However, CHW billing codes cannot be submitted for a member during the period they are actively enrolled in ECM. This exclusion is at the individual Medi-Cal member-level only, not the provider level. Many community-based organizations (CBOs) that provide ECM also provide CHW services, and CHW encounters may occur in managed care when allowable by policy and timing.
9. Whom can I contact if I have questions?
Los proveedores supervisores y los TCS pueden dirigir las preguntas de la siguiente manera:
- For questions about Fee-For-Service (FFS) billing, contact DHCS’
Telephone Service Center at (800) 541- 5555.
- For Managed Care questions, contact your local ManagedCare Plan.
- For Medi-Cal policy and benefits-related questions, contact DHCS’
Benefits Division at CHWBenefit@dhcs.ca.gov