Frequently Asked Questions (FAQs) For Medi-Cal Community Health Worker (CHW) Services-Clinics
The following FAQs provide additional guidance and clarification to Medi-Cal providers and members regarding CHW services and Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHCs), and tribal clinics. For more information regarding CHW services, please see the General Information FAQ for Medi-Cal Community Health Worker Services.
Clinics
- Can a FQHC or RHC be a supervising provider under Medi-Cal CHW policy?
No. Pursuant to the California Medicaid State Plan and current Medi-Cal policy, a supervising provider can only be a licensed provider; a hospital; an outpatient clinic as defined in Title 42 Code of Federal Regulations (CFR) section 440.90, which include a Indian Health Services (IHS) Memorandum of Agreement (MOA) 638 Clinic and Tribal FQHC; a pharmacy; a community-based organization (CBO); or a local health jurisdiction (LHJ).
- If FQHCs and RHCs cannot be supervising providers does that mean they cannot employ and utilize CHW services in their practices?
The current Medi-Cal policy does not prohibit FQHCs and RHCs from employing CHWs and offering CHW services in their practices. In fact, many FQHCs and RHCs currently employ and offer CHW services as part of their full spectrum of primary care services.
However, as noted in questions #6 and #7 below, these services are not reimbursable.
FQHCs and RHCs serving Medi-Cal members who are enrolled in managed care and receive health care services through their assigned Managed Care Plan (MCP) may bill CHW encounters to their MCPs. Pursuant to Welfare & Institutions Code (WIC) Section 14087.325(d), Medi-Cal MCPs are required to reimburse contracted FQHCs or RHCs in a manner that is no less than the level and amount of payment that the Medi-Cal MCP would make for the same scope of services if the services were furnished by another provider type that is not an FQHC or RHC. FQHCs and RHCs are required to report all Medi-Cal MCP payments received for the provision of CHW services on their annual reconciliation requests filed with DHCS unless such payments are managed care financial incentive payments excluded from the reconciliation process.
- Are MCPs required to reimburse FQHCs and RHCs for CHW services?
Yes. MCPs must reimburse FHCs and RHCs no less than the Medi-Cal Fee Schedule rate for CHW services (see also question #3 above). For MCPs under a capitated arrangement with FQHC and RHCclinics, CHW services are already built into the capitation payment. CHW services are not considered a PPS billable encounter and not eligible for the MCP differential rate (wrap) payment. For current MCP billing, claiming, payment, and access requirements, please refer to All-Plan Letter (APL) 24-006.
- Is the payment from the MCP reported to DHCS during the reconciliation process?
Yes. FQHCs and RHCs are required to report all MCP payments received for the provision of CHW services on their annual reconciliation reports filed with DHCS unless such payments are managed care financial incentive payments excluded from the reconciliation process.
- Can FQHCs and RHCs receive Prospective Payment System (PPS) reimbursement for CHW services from DHCS?
No. Pursuant to 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.
- 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 #4 above, the differential “wrap” payment is not permitted.
- What is the process if an FQHC or RHC does not have the cost of CHW services in their PPS rate and chooses to add the service?
In cases where an FQHC or RHC does not have the cost of CHW services in their PPS rate and chooses to add the service, they may be eligible to apply for a Change in Scope of Services (CSOSR) under WIC section 14132.100 (e) if they meet the specific criteria outlined in the statute to accommodate the additional services.
- For FQHCs and RHCs that have pharmacy services carved out of their PPS rate, does this change anything relative to the Medi-Cal CHW benefit given the addition of pharmacies as supervising providers as of October 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 or 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 or RHC’s scope of services enroll in Medi-Cal as a separate provider with a unique National Provider Identification (NPI) number.
- Can IHA-MOA Clinics and Tribal FQHCs receive reimbursement for CHW services?
Yes. DHCS reimburses IHS-MOA Clinics and Tribal FQHC for CHW services at the Medi- Cal FFS reimbursement rate. In addition, clinic regulations regarding the four walls of a Tribal 638 clinic do not apply to CHW services that are reimbursed at the Medi-Cal FFS rate, so they may be provided within the community when they are supervised by an IHS-MOA or Tribal FQHC.
- 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 (800) 541-5555.
- For questions about MCP billing, contact the MCP directly. To locate a member’s MCP, visit the Medi-Cal Managed Care Health Plan Directory | DHCS.
- For Medi-Cal policy and benefits-related questions, contact DHCS’ Benefits Division at CHWBenefit@dhcs.ca.gov.