Community Health Worker Medi-Cal Benefit: Implementation and the Role of Community Partners Like First 5

Community health workers (CHWs), promotores, and other non-licensed health professionals are frontline public health workers and trusted members of the communities they serve. They create a link between the community and health/social services, which are not always easy to navigate nor culturally responsive, to improve service access and quality. Given the powerful role CHWs can play in supporting health equity, California added Community Health Workers (CHWs) as a class of Medi-Cal providers effective July 2022 under both the fee-for-service (FFS) and managed care delivery systems. We have been focused on how the new CHW benefit may benefit infants and toddlers and their families in particular.

The new benefit offers Medi-Cal reimbursement to community health workers, promotores, or community health representatives. Covered services include health education, health navigation, screening and assessment, and individual support or advocacy and can be delivered in the community, outside of health care settings.

The focus of the benefit is prevention, and eligibility to receive CHW services is broad. Eligible individuals include Medi-Cal beneficiaries with unmet health-related social need such as housing, who have exposure to trauma, who would benefit from preventive services, or need support in health system navigation. Given low rates of preventive care access among children in Medi-Cal and how complicated health and social service systems can be to navigate in California, most young children with Medi-Cal coverage are eligible for CHW services.

Certain conditions must be met in order for services to be reimbursable by Medi-Cal. First, a CHW must have lived experience that aligns with the community or population being served and meet minimum qualifications. Starting in 2024, Medi-Cal-reimbursed CHWs will need to obtain a state-issued certificate. A certificate can be issued either by demonstrating prior experience (available through 2029) or by receiving training.

Second, CHWs need to be supervised by a licensed Medi-Cal provider. This entity is called the “supervising provider,” which is responsible for submitting claims for services and overseeing CHWs and the services they deliver. A community-based organization or an entity like a county First 5 can become a Medi-Cal provider and act as supervising provider for this benefit.

Third, a beneficiary needs a written recommendation from a physician or other licensed practitioner of the healing arts such a nurse, licensed clinical social worker, pharmacist, or mental health practitioner, to receive services. If services are needed for longer than 12 units (6 hours), a written plan of care must be developed by a licensed provider to describe the supports and services the CHW will provide to address the individual’s ongoing needs.

The Department of Health Care Services has positioned the CHW workforce as an important lever to support its quality goals, address health disparities in communities of color, and support access to basic population health management. To support implementation, managed care plans will be required to describe how they will integrate CHWs as part of Population Health Management requirements and monitor the percent of managed care plan members who received the CHW benefit.

The success of this benefit for young children in Medi-Cal hinges on Medi-Cal managed care plans enrolling child-serving CHW providers into their networks, as almost all children receive Medi-Cal coverage through managed care. This will be challenging as many CHWs who serve children operate in community-based settings. CBOs are not readily equipped to become Medi-Cal providers. Enrolling as a Medi-Cal provider and billing for medical services requires a cultural and operational shift that can be both daunting and costly for an organization.

Although they may need support in startup, First 5s are well positioned to be supervising providers for the CHW benefit, billing Medi-Cal managed care plans for the services they render directly, or through contracts with local CBOs. In this role, First 5s can function as a “hub” or point of contact for Medi-Cal managed care plans in coordinating and managing contracts with multiple direct service providers that serve young children. In turn, First 5s can support local CBOs with the administrative requirements of Medi-Cal billing.

First 5 county commissions invest in an array of family serving programming that meet the prevention, health education, health navigation, and screening focus of the CHW benefit. For example, home visiting and Help Me Grow improve health care outcomes for young children. Partnerships between Medi-Cal managed care plans and First 5s can catalyze the success of the CHW benefit for young children across the state, with powerful long-term impacts on the health and well-being of children facing adversity.