The following FAQs provide additional guidance and clarification to Medi-Cal members and providers regarding Medi-Cal policy requirements for CHWs and their supervising providers.

1.   What are the minimum qualifications to become a CHW in Medi-Cal?

In order to bill for CHW services provided to a Medi-Cal member, a CHW must have lived experience that aligns with and provides a connection between the CHW and the community or population being served. Additionally, a CHW must fulfill either the “Certificate Pathway” or “Work Experience Pathway”, as outlined in the Medi-Cal Provider Manual: Community Health Worker Preventive Services, as follows:

• Under the “Certificate Pathway”, CHWs must earn a “certificate of completion” by completing a program with a curricula that includes skills and/or practical training in the following areas: communication, interpersonal and relationship building, service coordination and navigation, capacity building, advocacy, education and facilitation, individual and community assessment, professional skills and conduct, outreach, evaluation and research, and basic knowledge in public health principles and social determinants of health (SDOH), as determined by the supervising provider. Certificate programs must also include field experience as a requirement.
• Under the “Work Experience Pathway”, CHWs must have more than 2,000 hours working in a paid or volunteer capacity within the previously three years and skills and/or practice training in the same areas as described in the “Certificate Pathway” requirements. In addition, CHWs must earn a “certificate of completion” consistent with the requirements outlined in the “Certificate Pathway” within 18 months of the first CHW visit provided to a Medi-Cal member.

For both, the supervising provider is responsible for ensuring and appropriately documenting that the program issuing the “certificate of completion” meets all Medi-Cal policy and related requirements outlined in the Medi-Cal Provider Manual and the CHW is therefore qualified to provide services to Medi-Cal members.   

2.   Does DHCS have a list of approved organizations that issue CHW certificates?

No. Under Medi-Cal policy, the supervising provider is solely responsible for determining if the certificate of completion fulfills all Medi-Cal CHW policy requirements and related requirements outlined in the Medi-Cal Provider Manual, including that the curricula for the CHW certificate of completion attests to demonstrated skills and/or practical training in certain core competencies, as well as field experience, as outlined in the Medi-Cal Provider Manual: Community Health Worker Preventive Services.

The Department of Health Care Services (DHCS) has developed an optional form, the CHW Minimum Qualification Checklist, as a tool to assist supervising providers with tracking and documenting minimum qualifications.

3.   Does the certificate of completion need to be issued or approved by the State of California?

No. The “certificate of completion” does not need to be approved by DHCS, the Department of Health Care Access and Information, or any other State agency. The “certificate of completion” can be issued by any program so long as it covers the core competencies, as well as field experience, as outlined in the Medi-Cal Provider Manual: Community Health Worker Preventive Services. Certificates can be issued by a California-based organization, an organization based in another state or even an international organization.

4.   Is there any additional required training for CHWs?

Yes. CHWs are required to complete a minimum of 6 hours of additional training annually. Training may be in the core competencies or an area of special focus. The supervising provider is responsible for maintaining appropriate supporting documentation showing that each CHW they supervise has satisfied all annual training requirements and shall make that information available to DHCS upon request and/or in the event of a state or federal audit.

DHCS has developed an optional form, the CHW Annual Continuing Training Checklist, as a tool to assist supervising providers with tracking and documenting the required annual training.

5.   Who can supervise CHWs?

The supervising provider is an enrolled Medi-Cal provider who submits claims for services provided by CHWs. The supervising provider ensures each CHW that they supervise meets the qualifications listed in the Medi-Cal Provider Manual: Community Health Worker Preventive Services, and directly or indirectly oversees each CHW and all services delivered to Medi-Cal members.

The supervising provider can be any of the following:

• Licensed provider, for example a doctor, nurse practitioner, etc.
• Hospital
• Outpatient clinic, as defined in title 42 of the Code of Federal Regulations section 440.90, which includes an Indian Health Services-Memorandum of Agreement 638 Clinic and a Tribal Federally Qualified Health Center
• Pharmacy
• Local health jurisdiction (LHJ), including County Children and Families’ Commissions (known as “First 5” agencies)
• Non-profit community-based organization (CBO)
• Local Educational Agency (LEA) or a public institution of higher education.

If you are not currently an enrolled Medi-Cal provider, you can enroll to become one and supervise CHWs by submitting an application through DHCS’  provider enrollment system.

6. Can LEAs or public institutions of higher education supervise and bill for CHW services?

Only LEAs or public institutions of higher education that are enrolled and bill as a CYBHI providers may bill for CHW services for CYBHI only. LEAs must bill for CHW services under CYBHI, which is provider type 112. LEAs and public institutions of higher education are not authorized to be CHW supervising providers outside of CYBHI and cannot bill for CHW services as an LEA Medi-Cal Billing Option Program service.

7.   Can a CHW with a violence prevention certificate provide CHW services?

A Violence Prevention Professional Certificate issued by Health Alliance for Violence Intervention or a certificate of completion in gang intervention training from the Urban Peace Institute allows a CHW to provide violence prevention services only. To provide the full range of CHW services, the individual must qualify through the “Certificate Pathway” or “Work Experience Pathway”.

8.   Can a CHW provide services for domestic violence prevention?

Yes, if the supervising provider determines that a CHW is qualified to render those services. Please note that domestic violence counselors, as defined in section 1037.1 of the Evidence Code, are not considered CHWs for purposes of Medi-Cal coverage and billing policy.

9.   Can a CHW provide asthma preventive services?

CHWs may provide CHW services to individuals with asthma, but evidence-based asthma self-management education and asthma trigger assessments may only be provided by asthma preventive service providers who have completed either a certificate from the California Department of Public Health Asthma Management Academy, or a certificate demonstrating completion of a training program consistent with the guidelines of the National Institutes of Health’s Guidelines for the Diagnosis and Management of Asthma. Please note that these services may also be rendered by a licensed provider within their scope of practice.

10. Can Peer Support Specialists (PSS) provide CHW services?

No. PSS are a separate provider type, and their services cannot be billed as CHW services, or vice versa. However, an individual can be certified as a PSS and as a CHW and separately provide either PSS or CHW services. Their supervising provider is responsible for ensuring they meet all Medi-Cal requirements for CHWs and there are no duplication of services.

11. Can CHWs provide services via telehealth?

Yes. CHW services may be provided via synchronous telehealth modalities when it is appropriate to do so and consistent with Medi-Cal policy. Synchronous telehealth modalities are real-time, two-way interactions between a Medi-Cal member and a provider, in which covered Medi-Cal services are rendered, which typically are going to be effectuated using audio-visual technology (for example, HIPAA-compliant video conferencing platforms) but may also be audio-only (for example, telephone calls) in limited circumstances outlined in Medi-Cal policy. CHWs must follow all existing Medi-Cal policies regarding delivery of covered services via telehealth modalities, including consent requirements. Supervising providers should refer to the Medi-Cal Provider Manual: Telehealth Modalities for guidance regarding providing covered CHW services via telehealth modalities. CHWs may not provide services via asynchronous telehealth modalities, including store and forward or e-consults, and services rendered by text, email, or chat are not eligible for reimbursement.

12.   Can CHWs provide public health services?

Medi-Cal coverage and billing policy for CHW services does not include broader public health services and are limited to those services listed in the Medi-Cal Provider Manual: Community Health Worker Preventive Services. Additionally, it is important to remember that CHW services must be specific to an individual Medi-Cal member’s health needs and not broader public health concerns in order to be considered medically necessary.

13.   What is a written plan of care? Is it required?

The plan of care, also known as a treatment plan, is a written document that is developed by one or more licensed providers that describe services a CHW will provide to address a Medi-Cal member’s ongoing needs for CHW services. A CHW may assist in developing a plan of care with the licensed provider(s), or may also draft a plan of care that identifies interventions for CHW services which is then reviewed and approved by a licensed provider. The plan of care may not exceed a period of one year.

For CHW services billed with Current Procedural Terminology (CPT) codes 98960, 98961, and 98962, a written plan of care is only required for continued CHW services after 12 units (equivalent to six hours) of care per member in a single year from initial date of service (excluding services provided in the Emergency Department).  The written plan of care may not exceed a period of one year. The plan of care must meet the following conditions:

• Specifies the condition that the service is being ordered for and be relevant to the condition.
• Includes a list of other health care professionals providing treatment for the condition or barrier.
• Contains written objectives that specifically address the member’s condition(s) or barrier(s) affecting their health.
• Lists the specific services required for meeting the written objectives.
• And includes the frequency and duration of CHW services (not to exceed the provider’s order) to be provided to meet the plan of care’s objectives.

For CHW services billed with Healthcare Common Procedure Coding System (HCPCS) codes G0019 and G0022, a treatment plan is developed by a licensed Medi-Cal provider (or drafted by a CHW but reviewed and approved a licensed Medi-Cal provider) is always required. The treatment plan must include the applicable ICD-10-CM diagnosis code(s) identifying the unmet SDOH needs, which were identified within the preceding six months during an initiating visit, and how the CHW services will help address the needs of the member.

14.   Can CHWs help Medi-Cal members maintain enrollment in Medi-Cal and/or initially enroll or maintain enrollment in another government or assistance program?

Yes. When billing for CPT codes 98960, 98961, and 98962 members meet the medical necessity criteria for CHW services when a member expresses the need for support in health navigation or resource coordination services, such as maintaining enrollment in Medi-Cal (including support with obtaining necessary documentation relative to enrollment) as well as both initial enrollment and maintaining enrollment in other government or assistance programs, such as CalWORKs or CalFRESH.

Similarly, when billing HCPCS codes G0019 and G0022, CHWs may provide health navigation or resource coordination services, but there must also be an identified unmet SDOH need (such as food insecurity, transportation insecurity, housing insecurity, and unreliable access to public utilities) that are significantly limiting a Medi-Cal provider’s ability to diagnose or treat problem(s) addressed in a Medi-Cal member’s initiating visit, including facilitating access to community-based social services (for example, housing, utilities, transportation, and food assistance.