Medi-Cal Coverage of Community Health Worker (CHW) Services is Effective July 1, 2022

June 29, 2022

Effective July 1, 2022, Medi-Cal covers CHW services, including violence prevention services and asthma preventive services.

This NewsFlash contains information describing the CHW benefit, including billing codes and rates. The description of the CHW benefit contained herein will also be included in a forthcoming update to the Provider Manual, which is scheduled to be released on July 15. Additional detail about asthma preventive services will also be included in the forthcoming Provider Manual update.

Program Coverage

Medi-Cal covers community health worker (CHW) services, pursuant to 42 CFR Section 440.130(c), as preventive services and on the written recommendation of a physician or other licensed practitioner of the healing arts within their scope of practice under state law.

CHW services may address issues that include, but are not limited to, the control and prevention of chronic conditions or infectious diseases; mental health conditions and substance use disorders; need for preventive services, perinatal health conditions; sexual and reproductive health; environmental and climate-sensitive health issues; child health and development; oral health; aging; injury; domestic violence; and violence prevention.

Definition

Community health worker (CHW) services are preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health.

Community health workers may include individuals known by a variety of job titles, including promotores, community health representatives, navigators, and other non-licensed public health workers, including violence prevention professionals, with the qualifications specified below.

The plan of care is a written document that is developed by one or more licensed providers, to describe the supports and services a CHW will provide to address ongoing needs for a beneficiary. A CHW may assist in developing a plan of care with the licensed provider.

The supervising provider is an enrolled Medi-Cal provider who submits claims for services provided by CHWs. The supervising provider ensures a CHW meets the qualifications listed in this document, and directly or indirectly oversees a CHW and their services delivered to Medi-Cal beneficiaries.  The supervising provider can be a licensed provider, a hospital, an outpatient clinic, a local health jurisdiction (LHJ), or a community-based organization (CBO). CHWs may be supervised by a CBO or LHJ that does not have a licensed provider on staff.

CHW violence preventive services are evidence-based, trauma-informed, and culturally responsive preventive services provided by an individual qualified through any of the pathways listed below, for the purpose of reducing the incidence of violent injury or reinjury, trauma, and related harms and promoting trauma recovery, stabilization, and improved health outcomes.

Covered Services-CHW Services:

  • Health education to promote the beneficiary’s health or address barriers to physical and mental health care, including providing information or instruction on health topics. The content of health education must be consistent with established or recognized health care standards. Health education may include coaching and goal-setting to improve a beneficiary’s health or ability to self-manage health conditions.

  • Health navigation to provide information, training, referrals, or support to assist beneficiaries to:

    • Access health care, understand the health care system, or engage in their own care.

    • Connect to community resources necessary to promote a beneficiary’s health; address health care barriers, including connecting to medical translation/interpretation or transportation services; or address health-related social needs.

    Note: Under health navigation, CHWs may provide the following:
    • Serving as a cultural liaison or assisting a licensed health care provider to create a plan of care, as part of a health care team.

    • Outreach and resource coordination to encourage and facilitate the use of appropriate preventive services.

    • Helping a beneficiary to enroll or maintain enrollment in government or other assistance programs that are related to improving their health, if such navigation services are provided pursuant to a plan of care.

  • Screening and assessment that does not require a license and that assists a beneficiary to connect to appropriate services to improve their health.

  • Individual support or advocacy that assists a beneficiary in preventing the onset or exacerbation of a health condition, or preventing injury or violence.

CHW violence prevention services include all the CHW services described above (health education, health navigation, screening and assessment, and individual support and advocacy), as these services apply specifically to violence prevention.

Services may be provided to a parent or legal guardian of a Medi-Cal beneficiary under age 21 for the direct benefit of the beneficiary, in accordance with a recommendation from a licensed provider. A service for the direct benefit of the beneficiary must be billed under the beneficiary’s Medi-Cal ID. If the parent or legal guardian of the beneficiary is not enrolled in Medi-Cal, the beneficiary must be present during the session.

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. (Note: These services may also be rendered by a licensed provider within their scope of practice.) For more information, please see Asthma Preventive Services section in Part 2 of the Provider Manual.

Non-Covered Services

  • Clinical case management/care management that requires a license

  • Child care

  • Chore services, including shopping and cooking meals

  • Companion services

  • Employment services

  • Helping a beneficiary enroll in government or other assistance programs that are not related to improving their health as part of a plan of care

  • 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 beneficiary

  • Transporting beneficiaries

  • Services provided to individuals not enrolled in Medi-Cal, except as noted above

  • Services that require a license

Although CHWs may provide CHW services to beneficiaries with mental health and/or substance use disorders, CHW services do not include Peer Support Services as covered under the Drug Medi-Cal, Drug Medi-Cal Organized Delivery System, and Specialty Mental Health Services programs. CHW services are distinct and separate from Peer Support Services.

Billing codes

The following CPT codes may be used for all services listed above by the supervising provider when submitting claims:

CPT code Description Length Number of Patients Rate
98960 self-management education and training, face-to-face, 30 minutes 30 minutes 1 $26.66
98961 self-management education and training, face-to-face, 30 minutes 30 minutes 2-4 $12.66
98962 self-management education and training, face-to-face, 30 minutes 30 minutes 5-8 $9.46

Maximum frequency is four units (two hours) daily per beneficiary, any provider. Additional units per day may be provided with an approved Treatment Authorization Request (TAR) for medical necessity. TARs may be submitted after the service was provided.

Telehealth

Supervising providers should refer to the Telehealth section in Part 2 of the Provider Manual for guidance regarding providing services via telehealth.

Documentation Requirements

CHW services require a written recommendation by a physician or other licensed practitioner of the healing arts within their scope of practice under state law. Other licensed practitioners who can recommend CHW services within their scope of practice include physician assistants, nurse practitioners, clinical nurse specialists, podiatrists, nurse midwives, licensed midwives, registered nurses, public health nurses, psychologists, licensed marriage and family therapists, licensed clinical social workers, licensed professional clinical counselors, dentists, licensed educational psychologists, licensed vocational nurses, and pharmacists.

CHWs are required to document the dates and time/duration of services provided to beneficiaries. Documentation should also reflect information on the nature of the service provided and support the length of time spent with the patient that day. For example, documentation might state, “Discussed the patient’s challenges accessing healthy food and options to improve the situation for 15 minutes. Assisted with SNAP application for 30 minutes. Referred patient to XYZ food pantry.” Documentation shall be accessible to the supervising provider upon request of the supervising provider.

Plan of Care

Providers are encouraged to develop a written plan of care when a need for multiple or ongoing CHW services is identified. A written plan of care is required for continued CHW services after 12 units of care per beneficiary in a single year, with the exception of services provided in the Emergency Department. The written plan of care must be developed by one or more licensed providers. The provider ordering the plan of care does not need to be the same provider who initially recommended CHW services or the supervising provider for CHW services. CHWs may participate on the team that develops the plan of care. The plan of care may not exceed a period of one year. The plan 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 recipient’s condition or barrier affecting their health.

  • Lists the specific services required for meeting the written objectives.

  • Includes the frequency and duration of CHW services (not to exceed the provider’s order) to be provided to meet the care plan’s objectives.

A licensed provider must review the beneficiary’s plan of care at least every six months from the effective date of the initial plan of care. The licensed provider must determine if progress is being made toward the written objective and whether services are still medically necessary. If there is a significant change in the recipient’s condition, providers should consider amending the plan for continuing care or discontinuing services if the objectives have been met.

Eligibility Criteria

CHW services are considered medically necessary for beneficiaries with one or more chronic health conditions (including behavioral health) or exposure to violence and trauma, who are at risk for a chronic health condition or environmental health exposure, who face barriers meeting their health or health-related social needs, and/or benefit from preventive services. The recommending provider shall determine whether a beneficiary meets the medical necessity criteria for CHW services based on the presence of one or more of the following:

  • Diagnosis of one or more chronic health (including behavioral health) conditions, or a suspected mental disorder or substance use disorder that has not yet been diagnosed

  • Presence of medical indicators of rising risk of chronic disease (e.g., elevated blood pressure, elevated blood glucose levels, etc., that indicate risk but do not yet warrant diagnosis of a chronic condition)

  • Positive Adverse Childhood Events (ACEs) screening

  • Presence of known risk factors, including domestic or intimate partner violence, tobacco use, excessive alcohol use, and/or drug misuse

  • Results of a social drivers of health screening indicating unmet health-related social needs, such as housing or food insecurity

  • One or more visits to a hospital emergency department within the previous six months

  • One or more hospital inpatient stays, including stays at a psychiatric facility, within the previous six months, or being at risk of institutionalization

  • One or more stays at a detox facility within the previous year

  • Two or more missed medical appointments within the previous six months

  • Beneficiary expressed need for support in health system navigation or resource coordination services

  • Need for recommended preventive services

CHW violence preventive services are available to a Medi-Cal beneficiary who meets any of the following circumstances:

  • The beneficiary has been violently injured as a result of community violence

  • A licensed health care provider has determined that the beneficiary is at significant risk of experiencing violent injury as a result of community violence

  • The beneficiary has experienced chronic exposure to community violence

Place of Service

There are no Place of Service restrictions for CHW services.

Claim Submission

Claims for CHW services must be submitted by the Medi-Cal enrolled supervising provider.

Supervision Requirements

CHWs must be supervised by a licensed provider, clinic, hospital, community-based organization, or local health jurisdiction. The supervising provider does not need to be the same entity as the provider who made the written recommendation for CHW services.

DHCS is working to add community-based organizations and local health jurisdictions in 2023 as new provider types who may supervise and bill for CHW services through fee-for-service Medi-Cal. In the meantime, DHCS will issue guidance on how managed care plans can engage various types of supervising providers to provide CHW services to beneficiaries enrolled in Medi-Cal managed care.

CHW Minimum Qualifications:

CHWs must have lived experience that aligns with and provides a connection between the CHW and the community or population being served. This may include, but is not limited to, lived experience related to incarceration, military service, pregnancy and birth, disability, foster system placement, homelessness, mental health conditions or substance use, or being a survivor of domestic or intimate partner violence or abuse and exploitation. Lived experience may also include shared race, ethnicity, sexual orientation, gender identity, language, or cultural background of one or more linguistic, cultural, or other groups in the community for which the CHW is providing services. Supervising providers are encouraged to work with CHWs who are familiar with and/or have experience in the geographic communities they are serving.

CHWs must demonstrate minimum qualifications through one of the following pathways, as determined by the supervising provider:

  • Certificate Pathway. CHWs demonstrating qualifications through the Certificate Pathway must provide proof of completion of at least one of the following certificates:

    1. CHW Certificate: A certificate of completion, including but not limited to any certificate issued by the State of California or a State designee, of a curricula that attests to demonstrated 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, as determined by the supervising provider. Certificate programs shall also include field experience as a requirement.

      A CHW Certificate allows a CHW to provide all covered CHW services described in this document, including violence prevention services.

    2. Violence Prevention Certificate: For individuals providing CHW violence prevention services only, a Violence Prevention Professional (VPP) Certification issued by Health Alliance for Violence Intervention or a certificate of completion in gang intervention training from the Urban Peace Institute.

      A Violence Prevention Certificate allows a CHW to provide CHW violence prevention services only. A CHW providing services other than violence prevention services shall demonstrate qualification through either the Work Experience Pathway or by completion of a General Certificate.

  • Work Experience Pathway: An individual who has 2,000 hours working as a CHW in paid or volunteer positions within the previous three years, and has demonstrated skills and practical training in the areas described above, as determined by the supervising provider, may provide CHW services without a certificate of completion for a maximum period of 18 months. A CHW who does not have a certificate of completion must earn a certificate of completion, as described above, within 18 months of the first CHW visit provided to a Medi-Cal beneficiary.

All CHWs must complete a minimum of 6 hours of additional training annually. The supervising provider shall maintain evidence of the CHWs completing continuing education requirements in case of audit.

Supervising providers may provide and/or require additional training, as identified by the supervising provider.