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23-267 Help Improve Patient Health Outcomes Through Community Health Worker (CHW) Services

Date: 04/10/23

Learn how to request CHW services to support patient’s health needs

In accordance with the Department of Health Care Services (DHCS) All Plan Letter (APL) 22-016 (PDF), Community Health Worker (CHW) services are considered preventive care services and are Medi-Cal covered benefits as of July 1, 2022.

Overview

CHWs provide health education and navigation services to help members get the care they need. CHWs are members of the community, such as community health representatives and non-licensed public health workers, including violence prevention professionals.

CHW services may assist with a variety of concerns impacting members, including but not limited to:

• Control and prevention of chronic conditions or infectious diseases.
• Behavioral health conditions.
• Perinatal care, preventive care, sexual and reproductive health.
• Environmental and climate-sensitive health issues.
• Oral health, aging and injury.
• Domestic violence and other violence prevention services.

Member eligibility for CHW services

CHW services must be recommended by a physician or other licensed practitioner. The physician or licensed practitioner does not need to be enrolled in Medi-Cal or be in-network. The physician or licensed practitioner must ensure that a member meets eligibility criteria below before recommending CHW services:

• Member must be enrolled in Medi-Cal.
• Members 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 in meeting their health or health-related social needs, and/or
  • Who would benefit from preventive services.
• A written recommendation must be submitted to California Health & Wellness Plan (CHWP) for CHW services to be administered.

Covered services and documentation

The following categories are covered CHW services:

1. Health education – Services that promote health or address barriers to physical and mental health care. This includes providing information on health topics.
2. Health navigation – Services providing information, training, referrals or assistance to help members access health care. Examples include increasing member knowledge of the health care delivery system, or how members can engage in their own care.
3. Screening and assessment – Providing screening and assessment services that do not require a license, and assisting a Member with connecting to appropriate services to improve their health.
4. Individual support or advocacy – Assisting a Member in preventing the onset or exacerbation of a health condition, or preventing injury or violence. This includes peer support as well if not duplicative of other covered benefits.

CHWs are required to document the dates and time/duration of services provided to members. 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 detailed information on covered and non-covered services, billing, claims and payments, refer to APL 22-016 (PDF).

CHW supervising provider

Supervising providers are organizations employing or otherwise overseeing the CHWs contracted with CHWP.  The supervising provider must:

• Ensures that CHWs meet the qualifications listed in APL 22-016 (PDF).
• Oversee CHW services delivered to members.
• Submit claims for services provided by CHWs with allowable current procedural terminology (CPT) codes as outlined in the Medi-Cal Provider Manual.

CHW supervising providers are reimbursed for CHW services in accordance with the provider contract.

California Health & Wellness Plan asks that CHW supervising providers meet these minimum requirements:

• Be a licensed provider, hospital, outpatient clinic, local health jurisdiction (LHJ) or community-based organization (CBO).
• Have a National Provider Identifier (NPI).
• Ability to receive referrals from licensed practitioners for CHW benefits.
• Ability to submit claims or encounters to California Health & Wellness Plan using standardized protocols.
• Ensure your business license meets industry standards.
• Ability to comply with all reporting and oversight requirements.
• Ensure CHWs have sufficient experience to provide services.

Additional communications will be forthcoming to provide further information on steps to becoming a CHW supervising provider.

Additional information

Providers are encouraged to access California Health & Wellness Plan ’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact California Health & Wellness Plan at 877-658-0305.

 

This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.