Community-Based Organizations, Local Health Jurisdictions, and County Children and Families Commissions Application Information
Community-Based Organizations (CBOs) that provide community health worker (CHW), asthma preventive (AP), or justice-involved (JI) services, and local health jurisdictions (LHJs) and county children and families commissions that provide CHW or AP services may apply to enroll in the Medi-Cal program by submitting an electronic application through the Provider Application and Validation for Enrollment (PAVE) online enrollment portal, along with all supporting documentation. When applying through PAVE, county children and families commission providers may select LHJ from the dropdown menu.
Based upon the authority granted to the Director of the Department of Health Care Services (DHCS) in accordance with Welfare & Institutions Code (W&I) Section 14043.75(b), the DHCS Director is establishing the specific application and enrollment requirements for CBO, LHJ, and county children and families commissions that apply for enrollment in the Medi-Cal program to be reimbursed for the covered services they provide to Medi-Cal members. These requirements implement and make specific W&I Code Sections 14043.15 and 14043.26, and as such have the full force and effect of law. For more information, please see the updated regulatory provider bulletin titled, “Updated Medi-Cal Enrollment Requirements and Procedures for Community-Based Organizations, Local Health Jurisdictions and County Children and Families Commissions.” Also, this bulletin does not substitute for, or eliminate, all other enrollment requirements set forth in W&I Code Section 14043.26.
Medi-Cal Program Requirements
A CBO provider must be a public or private non-profit organization with a 501(c)(3) status or a fiscally sponsored entity of a 501(c)(3) non-profit organization. An LHJ provider must be a local health department as defined in Health & Safety Code Section 101185. A county children and families commission must be established pursuant to H&S Code Section 130100 et seq.
All applicants must meet current Medi-Cal provider enrollment requirements and standards as well as the requirements set forth in the aforementioned bulletin. Furthermore, Medi-Cal enrollment standards require applicants abide by all state and local laws and ordinances pursuant to California Code of Regulations (CCR), Title 22, Sections 51000.30(e) and 51000.60(c).
Required Documents
Gather the required documents listed below, as applicable, in order to upload them into PAVE as you complete your PAVE application. Please ensure the uploaded documents are legible.
- Federal Employer Identification Number (FEIN) or Individual Taxpayer Identification Number (ITIN) verification, if a social security number is not used, by submitting a current Internal Revenue Service (IRS) generated document. The only acceptable documents include an IRS-generated Letter 147-C, IRS-generated Form 941 (Employer’s Quarterly Federal Tax Return), IRS-generated Form 8109-C (Deposit Coupon), or IRS-generated Form SS-4 (only the official Confirmation Notification of FEIN/ITIN assignment). Note: The legal name of the applicant or provider on the application must exactly match the name on the IRS-generated document; and the applicant/provider must be an owner or officer of the entity listed on the IRS document. For further information, please visit the IRS call them at (800) 829-4933.
- Local Business License, Tax Certificate, and Permit for any city and/or county where activities are conducted. Note: The name and business address of the applicant or provider on the application must match the business name and business address on all local licenses and permits. For further information, please contact your city business license office and/or visit the California State Association of Counties website and click on the "California's Counties" link, and select "County Websites & Profile Information."
- 501(c)(3) Documentation for CBO providers with a 501(c)(3) status. A CBO that is a fiscally sponsored entity of a 501(c)(3) non-profit organization must provide a letter from the sponsoring entity that attests to their arrangement and status and proof of the 501(c)(3) status for the sponsoring entity. This letter must be on the sponsoring entity’s letterhead.
- Certificate of Commercial Liability Insurance (business, general, or comprehensive liability, or office premises insurance) in an amount of not less than $100,000 per claim and a minimum annual aggregate of $300,000. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name and business address of the insured, effective dates, and limits of coverage. Note: The name and business address, including suite number if applicable, of the applicant or provider on the application must exactly match the insured’s name and address on the certificate of insurance or declaration sheet.
- Certificate of Workers’ Compensation Insurance is required by California law, if your business has one or more employees. Acceptable verification is either evidence of being self-insured, or a certificate of insurance or declaration sheet issued by the insurance company that contains the name of the insurance company, the name of the insured, and effective dates. If no Workers’ Compensation insurance is required, an explanation must be provided. Note: The name of the applicant or provider must exactly match the insured’s name on the certificate of insurance.
- Signed Lease Agreement, if business premises are not owned by the applicant or provider. Note: The name and business address of the applicant or provider must exactly match the lessee’s name and address on the lease agreement. For CBOs, a written verification may be provided from the space owner that the space is being donated for the purposes of operating a CBO at no cost.
- Successor Liability with Joint and Several Liability Agreement (DHCS 6217), if applicable.
PAVE Portal
Proceed to the
PAVE portal.
