这​​  下列的​​  常见问题解答​​  提供​​  额外的​​  指导​​  和​​  澄清​​  到​​  Medi-Cal​​  提供者和成员有关 CHW 服务和联邦合格健康中心 (FQHC)、农村卫生诊所 (RHC) 和部落诊所的信息。欲了解有关社区卫生工作者 (CHW) 服务的更多信息，​​  请​​  看​​  这​​  Medi-Cal 社区 保健员 服务 一般 信息 常见问题解答。 工人服务。​​ 

1. FQHC 或 RHC 可以成为 Medi-Cal CHW 政策下的监督提供者吗？​​ 

不可以。根据加州医疗补助州计划和现行 Medi-Cal 政策，监督提供者只能是持照提供者；医院；《联邦法规》（CFR）第 42 篇第 440.90 节定义的门诊诊所，其中包括印第安健康服务 (IHS) 协议备忘录 (MOA) 638 诊所和部落联邦合格健康中心 (FQHC)；药房；社区组织 (CBO)；或地方卫生管辖区 (LHJ)。​​ 

2. 如果 FQHC 和 RHC 不能监督服务提供商，是否意味着他们不能在实践中雇用和利用 CHW 服务？​​ 

当前的 Medi-Cal 政策并不禁止 FQHC 和 RHC 雇用 CHW 并在其实践中提供 CHW 服务。事实上，许多 FQHC 和 RHC 目前都聘用并提供 CHW 服务作为其全方位初级保健服务的一部分。​​ 

但是，正如下面问题 5 和问题 6 所述，这些服务是不可报销的。​​ 

3. CHW 如何为为 Medi-Cal 管理式医疗成员提供服务的 FQHC 和 RHC 开具账单？​​ 

为参加管理式医疗并通过其指定的管理式医疗计划 (MCP) 接受医疗保健服务的 Medi-Cal 会员提供服务的 FQHC 和 RHC 可以将 CHW 就诊费用记入其 MCP 账户。根据《合同与赔偿法》第 14087.325(d) 条，Medi-Cal MCP 必须以不低于 Medi-Cal MCP 为签约的 FQHC 或 RHC 提供相同范围服务时支付的水平和金额的方式报销这些服务，前提是这些服务是由非 FQHC 或 RHC 的其他提供商类型提供的。FQHC 和 RHC 必须在向 DHCS 提交的年度对账请求中报告为提供 CHW 服务而收到的所有 Medi-Cal MCP 付款，除非此类付款是被排除在对账流程之外的管理式医疗财务激励付款。​​ 

4. 在对账过程中，MCP 的付款是否会报告给 DHCS？​​ 

是的。家庭合格医疗中心 (FQHC) 和区域医疗中心 (RHC) 必须在其向卫生和消费者服务部 (DHCS) 提交的年度对账报告中报告所有因提供社区卫生工作者 (CHW) 服务而收到的管理式医疗 (MCP) 付款，除非此类付款属于管理式医疗财务激励付款，且不包含在对账流程中。​​   

5. FQHC 和 RHC 能否从 DHCS 获得 CHW 服务的预付费系统 (PPS) 报销？​​ 

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. 如果 FQHC 或 RHC 的 PPS 费率中不包含 CHW 服务费用并选择添加该服务，流程是怎样的？​​ 

如果 FQHC 或 RHC 的 PPS 费率中不包含 CHW 服务费用并选择添加该服务，则如果他们符合法规中概述的具体标准以提供额外服务，则他们可能有资格根据 WIC 第 14132.100 (e) 节申请变更服务范围 (CSOSR)。​​ 

8. 对于已将药房服务从其 PPS 费率中剔除的 FQHC 和 RHC，鉴于自 10 月1和2024起增加药房作为监督提供商，这是否会对 Medi-Cal CHW 福利产生任何影响？​​ 

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 计划在未来的 Medi-Cal 政策公告中发布有关该主题的进一步指导。​​ 

9. IHA-MOA 诊所和部落 FQHC 可以获得 CHW 服务的报销吗？​​ 

是的。DHCS 按照 Medi-Cal FFS 报销率向 IHS-MOA 诊所和部落 FQHC 报销社区卫生工作者 (CHW) 服务费用。此外，有关部落 638 诊所四面墙的诊所规定不适用于以 Medi-Cal FFS 费率报销的 CHW 服务，因此在 IHS-MOA 或部落 FQHC 的监督下，可以在社区内提供这些服务。​​ 

10.如果 Medi-Cal 会员正在接受 CalAIM 下的 Medi-Cal 管理式医疗计划提供的增强护理管理(ECM) 服务，他们也可以接受 CHW 服务吗？​​ 

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. 如果有疑问，我可以联系谁？​​ 

监督提供者和社区卫生工作者可以提出以下问题：​​ 

• For questions about Fee-For-Service (FFS) billing, contact DHCS’ Telephone Service Center at (800) 541-5555.​​ 
• 有关 Medi-Cal 政策和福利相关问题，请联系 DHCS 福利部，电子邮件：CHWBenefit@dhcs.ca.gov。​​