FREQUENTLY ASKED QUESTIONS (FAQs) FOR MEDI-CAL COMMUNITY HEALTH WORKER (CHW) SERVICES-General Information
The following FAQs provide additional guidance and clarification to Medi-Cal members and providers regarding CHW services.
General Information
1. What is a CHW?
CHWs are unlicensed, trained health educators who work with individuals who may have difficulty understanding providers due to cultural or language barriers to connect them with the services they need. CHWs include individuals known by a variety of job 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?
CHWs may provide the following services:
- Health education to promote the Medi-Cal member's health or address barriers to health care, including providing information or instruction on health topics.
- Health navigation to provide information, training, referrals, or support to assist Medi-Cal members to access health care, understand the health care system, and engage in their own care and to connect members to community resources necessary to promote their health.
- Screening and assessment that assist Medi-Cal members to connect to appropriate services to improve their health.
- Individual support or advocacy that assists Medi-Cal members in preventing the onset or exacerbation of a health condition or preventing injury or violence.
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, 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.
Additionally, on April 1, 2025, DHCS issued a statewide standing recommendation that all Medi-Cal members who meet the defined eligibility criteria for receiving CHW services would benefit from CHW services. This standing recommendation was issued to improve access and reduce barriers to Medi-Cal members receiving and Medi-Cal providers rendering CHW services, and was signed by the DHCS Medical Director, Dr. Karen Mark. 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. Consistent with existing policy, this standing recommendation will authorize CHWs to provide up to 12 units annually members of covered Medi-Cal CHW services including health education, health navigation, screening and assessment, and individual support and advocacy, which can be reimbursed using established billing codes 98960-98962 and subject to all frequency and other policy requirements as outlined in Medi-Cal's policy, including a frequency limit of 4.0 units (2.0 hours) per day
4. Who is eligible to receive violence preventive services (VPS)?
CHW community VPS are available to a Medi-Cal member who meets any of the following circumstances, as recommended by a licensed provider:
- The Medi-Cal member has been violently injured as a result of community violence.
- A licensed provider has determined that the Medi-Cal member is at significant risk of experiencing violent injury as a result of community violence.
- The Medi-Cal member has experienced chronic exposure to community violence.
CHWs may also provide services to Medi-Cal members experiencing intimate partner and domestic violence.
5. What services may not be provided by a CHW?
Medi-Cal does not reimburse for the following services when rendered by a CHW:
- Clinical case management/care management that requires a license.
- Childcare
- Chore services, including shopping and cooking.
- Companion services
- Employment services
- Helping a member enroll in government programs or insurance that is not related to improving their health as part of a care 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.
- Socialization
- Transportation
- Services provided to individuals not enrolled in Medi-Cal, except as noted above
- Services that require a license
Additional Questions
6. 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?
DHCS recognizes that many ECM providers are now also starting to provide CHW services. As a result, DHCS expects to see CHW encounters in managed care for CHW services provided to Medi-Cal members by community-based organizations (CBOs) who are also ECM providers. To this end, DHCS wants to clarify that the billing exclusion is at the individual Medi-Cal member-level only for the period of time they are enrolled in ECM, 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 at that period in time, but they can (and many do) bill for CHW services for Medi-Cal members before they are authorized for ECM, after they graduate from the ECM program, and for members who may refuse or otherwise be ineligible for ECM.
7. Whom can I contact if I have questions?
Supervising providers and CHWs may direct questions as follows:
- For questions about Fee-For-Service (FFS) billing, contact DHCS'
Telephone Service Center at 1- 800-541- 5555.
