Cov​​  raws​​  FAQs​​  muab​​  ntxiv​​  Kev taw qhia​​  thiab​​  kev qhia meej​​  rau​​  Medi-Cal​​  Cov chaw muab kev pabcuam thiab cov tswvcuab hais txog CHW cov kev pabcuam thiab Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv Hauv Tebchaws (FQHC), Cov Tsev Kho Mob Hauv Nroog (RHC), thiab cov tsev kho mob pab pawg neeg. Yog xav paub ntxiv txog CHW cov kev pabcuam,​​  thov​​  saib​​  tus​​  Cov Lus Qhia Dav Dav FAQ rau Medi-Cal Community Health  Cov Kev Pabcuam Rau Cov Neeg Ua Haujlwm.​​ 

1. FQHC lossis RHC puas tuaj yeem ua tus saib xyuas raws li Medi-Cal CHW txoj cai?​​ 

Tsis yog. Ua raws li California Medicaid State Plan thiab Medi-Cal txoj cai tam sim no, tus kws saib xyuas tsuas tuaj yeem yog tus muab ntawv tso cai xwb; tsev kho mob; ib lub chaw kho mob sab nraud raws li tau hais tseg hauv Title 42 Code of Federal Regulations (CFR) section 440.90, uas suav nrog Indian Health Services (IHS) Memorandum of Agreement (MOA) 638 Clinic thiab Tribal Federally Qualified Health Center (FQHC); lub tsev muag tshuaj; lub koom haum hauv zej zog (CBO); los yog lub chaw saib xyuas kev noj qab haus huv hauv cheeb tsam (LHJ).​​ 

2. Yog tias FQHCs thiab RHCs tsis tuaj yeem saib xyuas cov chaw muab kev pab txhais tau tias lawv tsis tuaj yeem ntiav thiab siv CHW cov kev pabcuam hauv lawv cov kev coj ua?​​ 

Txoj cai Medi-Cal tam sim no tsis txwv FQHCs thiab RHCs los ntawm kev ntiav CHWs thiab muab CHW cov kev pabcuam hauv lawv cov kev coj ua. Qhov tseeb, ntau FQHCs thiab RHCs tam sim no ntiav thiab muab CHW cov kev pabcuam uas yog ib feem ntawm lawv cov kev pabcuam thawj zaug.​​ 

Txawm li cas los xij, raws li tau sau tseg hauv cov lus nug #5 thiab #6 hauv qab no, cov kev pabcuam no tsis tuaj yeem them rov qab.​​ 

3. Kev them nqi CHW ua haujlwm li cas rau FQHCs thiab RHCs pabcuam Medi-Cal cov tswvcuab saib xyuas?​​ 

FQHCs thiab RHCs pabcuam Medi-Cal cov tswvcuab uas tau tso npe rau hauv kev saib xyuas kev tswj hwm thiab tau txais cov kev pabcuam kev noj qab haus huv los ntawm lawv qhov kev pabcuam Managed Care Plan (MCP) tuaj yeem sau nqi CHW ntsib rau lawv MCPs. Ua raws li W&I Code Tshooj 14087.325(d), Medi-Cal MCPs yuav tsum tau them rov qab FQHCs lossis RHCs uas tau cog lus tsis pub tsawg tshaj li theem thiab cov nyiaj them uas Medi-Cal MCP yuav ua rau tib qhov kev pabcuam yog tias cov kev pabcuam tau muab los ntawm lwm tus neeg muab kev pabcuam uas tsis yog FQHC lossis RHC. FQHCs thiab RHCs yuav tsum tau tshaj tawm tag nrho cov nyiaj Medi-Cal MCP tau txais rau kev muab CHW cov kev pab cuam ntawm lawv daim ntawv thov kev sib haum xeeb txhua xyoo uas tau thov rau DHCS tshwj tsis yog tias cov nyiaj them no raug tswj xyuas kev them nyiaj txhawb nqa nyiaj txiag tsis suav nrog cov txheej txheem kev sib haum xeeb.​​ 

4. Puas yog cov nyiaj them los ntawm MCP tau tshaj tawm rau DHCS thaum lub sijhawm sib koom ua ke?​​ 

Yog lawm. FQHCs thiab RHCs yuav tsum tau tshaj tawm tag nrho cov nyiaj MCP tau txais rau kev muab CHW cov kev pabcuam ntawm lawv cov ntaub ntawv qhia txog kev sib haum xeeb txhua xyoo uas tau xa mus rau DHCS tshwj tsis yog tias cov nyiaj them ntawd raug tswj hwm kev saib xyuas nyiaj txiag txhawb nqa kev them nyiaj tsis suav nrog cov txheej txheem kev sib haum xeeb.​​   

5. FQHCs thiab RHCs puas tuaj yeem tau txais Cov Nyiaj Them Nqi Ntxiv (PPS) rov qab rau CHW cov kev pabcuam los ntawm DHCS?​​ 

No. Pursuant to Welfare and Institution Code (WIC) section 14132.10 (g) and Attachment 4.19-B of the California Medicaid State Plan, only visits with specified physicians and other non-physician health professionals are PPS reimbursable visits. The services provided by CHWs are not considered PPS eligible visits; rather, they are categorized as “incident to” physician services and do not qualify for PPS reimbursement. DHCS would also note that the PPS rate is designed to reimburse FQHCs and RHCs for the average projected per-visit cost of all allowable Medi-Cal services, including CHWs, which are already built into their rate and thus would be another reason why FQHCs and RHCs cannot bill separately for CHW services.​​ 

6.   Can FQHCs and RHCs receive the differential “wrap” payment for CHW services from DHCS?​​ 

No. According to WIC section 14132.100(h), DHCS reimburses FQHCs and RHCs for the difference between the payments received from MCPs and the payments that the FQHC or RHC would have received under the PPS for eligible visits. Since CHW services are not PPS eligible visits and are not reimbursed at the PPS rate, as noted in question #5 above, the differential “wrap” payment is not permitted.​​ 

7. Yuav ua li cas yog tus FQHC lossis RHC tsis muaj tus nqi ntawm CHW cov kev pabcuam hauv lawv tus nqi PPS thiab xaiv ntxiv cov kev pabcuam?​​ 

Nyob rau hauv rooj plaub uas FQHC lossis RHC tsis muaj tus nqi ntawm CHW cov kev pabcuam hauv lawv tus nqi PPS thiab xaiv ntxiv cov kev pabcuam, lawv tuaj yeem tsim nyog thov rau Kev Hloov Kho Kev Pabcuam (CSOSR) raws li WIC ntu 14132.100 (e) yog tias lawv ua tau raws li cov txheej txheem tshwj xeeb tau teev tseg hauv txoj cai kom haum rau cov kev pabcuam ntxiv.​​ 

8. Rau FQHCs thiab RHCs uas muaj cov chaw muag tshuaj muab tshem tawm ntawm lawv tus nqi PPS, qhov no puas hloov pauv ib yam dab tsi cuam tshuam rau Medi-Cal CHW cov txiaj ntsig tau muab ntxiv ntawm cov khw muag tshuaj los ua tus saib xyuas txij li lub Kaum Hlis 1, 2024?​​ 

As of October 1, 2024, Medi-Cal enrolled pharmacy providers are able to supervise CHWs and bill for covered CHW services that support pharmacy services, such as health education, health navigation, screening and assessment, and individual support or advocacy. CHWs are not able to provide any pharmacy-related services that require a professional license. Accordingly, enrolled pharmacy providers associated with FQHCs or RHCs that have pharmacy services carved out of the PPS rate may bill CHW services that support pharmacy services. Enrolled pharmacy providers associated with FQHCs or RHCs may not bill CHW services that do not support pharmacy services or that are otherwise reflected in the FQHC’s/RHC’s scope of services or existing PPS rate.​​ 

Pursuant to subdivision (k) of WIC section 14132.100, FQHCs and RHCs may elect to have pharmacy services carved out of the PPS reimbursement rate and be reimbursed for pharmacy services on a fee-for-service basis. Upon election, costs associated with pharmacy services are adjusted out of the FQHC’s or RHC’s PPS rate. Pharmacies that have been carved out of an FQHC’s/RHC’s scope of services enroll in Medi-Cal as a separate provider with a unique National Provider Identification (NPI) number.​​ 

DHCS tab tom npaj yuav tshaj tawm cov lus qhia ntxiv txog cov ncauj lus no hauv tsab ntawv tshaj tawm txoj cai Medi-Cal yav tom ntej.​​ 

9. IHA-MOA Clinics thiab Tribal FQHC puas tuaj yeem tau txais cov nyiaj them rov qab rau cov kev pabcuam CHW?​​ 

Yog lawm. DHCS them nyiaj rov qab rau IHS-MOA Clinics thiab Tribal FQHC rau CHW cov kev pabcuam ntawm Medi- Cal FFS cov nyiaj rov qab. Tsis tas li ntawd, cov kev cai hauv tsev kho mob hais txog plaub phab ntsa ntawm Tribal 638 lub tsev kho mob tsis siv rau CHW cov kev pabcuam uas tau them rov qab los ntawm Medi-Cal FFS tus nqi, yog li lawv tuaj yeem muab rau hauv zej zog thaum lawv raug saib xyuas los ntawm IHS-MOA lossis Tribal FQHC.​​ 

10.  Yog tias ib tug tswv cuab ntawm Medi-Cal tau txais cov kev pab cuam Enhanced Care Management (ECM) uas muab los ntawm Medi-Cal txoj kev npaj kho mob raws li CalAIM, lawv puas tuaj yeem tau txais cov kev pabcuam CHW?​​ 

DHCS recognizes that many ECM providers are starting to provide standalone CHW services. For clarification, providers must not “double bill” both ECM and CHW services for the same Member, during the same time period. The scope of ECM is broad and is inclusive of all the services within the CHW benefit. Thus, billing a standalone CHW service for a Member receiving ECM is duplicative. For Members not yet enrolled in ECM, CHW providers may provide outreach for ECM and bill for this outreach through the standalone CHW benefit if the following conditions are met. First, outreach for ECM enrollment may only be billed under the standalone CHW benefit if the same provider is not receiving payment from an MCP for the same outreach through ECM. Second, all other requirements for the CHW benefit must be met whenever this benefit is used for ECM outreach. Of note, the exclusion for double billing is determined at the member level, not the provider level. In practice, this means that providers cannot submit claims for the CHW billing codes for Medi-Cal members who are actively receiving ECM during a date of service. However, these providers can bill for CHW services for Medi-Cal members prior to ECM enrollment after they graduate or conclude ECM services if a member refuses or is otherwise ineligible for ECM.​​ 

11. Kuv tuaj yeem hu rau leej twg yog kuv muaj lus nug?​​ 

Cov kws saib xyuas thiab CHWs tuaj yeem nug cov lus nug hauv qab no:​​ 

• For questions about Fee-For-Service (FFS) billing, contact DHCS’ Telephone Service Center at (800) 541-5555.​​ 
• Yog koj muaj lus nug txog txoj cai Medi-Cal thiab cov txiaj ntsig, hu rau DHCS' Benefits Division ntawm CHWBenefit@dhcs.ca.gov.​​