The​​  以下​​  常見問題解答​​  提供​​  額外的​​  指導​​  和​​  澄清​​  至​​  Medi-Cal​​  有關 CHW 服務和聯邦合格健康中心（FQHC），農村健康診所（RHCs）和部落診所的提供商和成員。有關 CHW 服務的更多信息，​​  請​​  請參閱​​  該​​  Medi-Cal 社區 保健 員服務 一般 資訊常見問題 。 工人服務。​​ 

1.根據 Medi-Cal CHW 政策下，FQHC 或 RHC 可以成為監督供應商嗎？​​ 

不根據加州 Medicaid 州立計劃和目前的 Medi-Cal 政策，監督提供者只能是持牌提供者；醫院；第 42 章聯邦法規守則（CFR）第 440.90 條定義的門診診所，其中包括印度健康服務（IHS）協議備忘錄（MOA）638 診所和部落聯邦合格健康中心（FQHC）；藥房；社區組織（CBO）)；或當地衛生管轄區（LHJ）。​​ 

二.如果 FQHC 和 RHCs 無法監督供應商，那麼這意味著他們不能在其實踐中僱用和利用 CHW 服務？​​ 

現行的 Medi-Cal 政策並不禁止 FQHC 及 RHC 在其實踐中僱用 CHW 和提供 CHW 服務。事實上，許多 FQHC 和 RHCs 目前僱用和提供 CHW 服務，作為其全面基層醫療服務的一部分。​​ 

但是，正如下問題 #5 和 #6 中所述，這些服務不得退款。​​ 

三.服務 Medi-Cal 託管護理會員的 FQHC 和 RHC 的 CHW 計費如何運作？​​ 

服務於醫療服務成員的 FQHC 和 RHCs，如註冊受管理護理並通過指定的託管護理計劃（MCP）接受醫療保健服務，可向其 MCP 收取醫療保健服務。根據 W & I 守則第 14087.325 (d) 條，如果服務由其他非 FQHC 或 RHCC 提供的服務類型，Medi-Cal MCP 必須以不低於 Medi-Cal MCP 為相同範圍的服務所支付的付款水平和金額的方式退還合約的 FQHC 或 RHCS。除非該等款項屬於調節程序中排除了管理照護理財激勵金融獎勵付款，否則 FQHC 和 RHCS 須根據提交給 DHCS 提交的年度調節請求，否則該等款項為提供 CHW 服務所收到的所有 Medi-Cal MCP 付款。​​ 

4.在調解過程中，MCP 的付款是否向 DHCS 報告？​​ 

是的除非該等付款屬於調節程序中排除了管理照護理財經激勵金融補助金，否則 FQHC 和 RHCS 須在提交給 DHCS 提交的年度調節報告中報告所收到的所有 MCP 付款。​​   

5.衞生防護中心和食物管理局是否可以獲得預期支付系統（PPS）的補助金融服務？​​ 

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.​​ 

七.如果 FQHC 或 RHC 在 PPS 費率中沒有 CHW 服務的成本，並選擇添加該服務，該過程如何？​​ 

如果 FQHC 或 RHC 在其 PPS 費率中沒有含有 CHW 服務費用，而且選擇加入該服務，則如果他們符合條例中列明的特定標準以適應其他服務，則可能符合《WIC》第 14132.100 (e) 條的服務範圍變更。​​ 

八.由於自 2024 年 10 月 1 日起，將藥房成為監管提供者的藥房服務的 FQHC 和 RHCS 來說，這是否與 Medi-Cal CHW 保障有任何改變？​​ 

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 計劃在未來的 Medi-Cal 政策公告中發布有關此主題的進一步指導。​​ 

九.IHA-MOA 診所和部落健康服務中心是否可以獲得醫療保健服務的補償？​​ 

是的DHCS 按照醫療 FFS 補償率向 IHS-MOA 診所和部落 FQHC 的 CHW 服務退款。此外，關於部落 638 診所四牆的診所規定不適用於按 Medi-Cal FFS 費率退還的 CHW 服務，因此在 IHS-MOA 或部落 FQHC 監督時，可能會在社區內提供這些服務。​​ 

十.如果 Medi-Cal 會員接受由 CalAIM 下的 Medi-Cal 託管護理計劃提供的加強護理管理 (ECM) 服務，他們也可以接受 CHW 服務嗎？​​ 

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.​​ 

十一.如果我有疑問，我可以聯繫誰？​​ 

監督供應商及衞生防護中心可提出以下質詢：​​ 

• For questions about Fee-For-Service (FFS) billing, contact DHCS’ Telephone Service Center at (800) 541-5555.​​ 
• 有關 Medi-Cal 政策和福利相關問題，請聯絡 DHCS 福利部門，電子郵件地址為CHWBenefit@dhcs.ca.gov。​​