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Community Health Worker Benefit

Effective July 1, 2022, Community Health Worker (CHW) services are a covered Medi-Cal benefit. These services are preventive health services delivered by a CHW to prevent disease, disability and other health conditions or their progression; to prolong life; and to promote physical and mental health. Providers who employ CHWs to assist with Member outreach and support, can bill Inland Empire Health Plan (IEHP) for services rendered.

 

For further Information about the Community Health Worker Benefit:

 

 

Covered Services

  • Promote Member health or address barriers to physical and mental health care, such as providing information or instructions on health topics. 
  • May include coaching and goal setting to improve Member health outcomes or ability to self-manage their health conditions.

  • Provide information, training, referrals, or support to assist Members in accessing health care, understand the health care delivery system, or engage in their own care.
  • Assist with plan of care.
  • Perform outreach and resource coordination to encourage and facilitate the use of appropriate preventive services.
  • Help a Member enroll or maintain enrollment in government or other assistance programs.

  • Provide screening and assessment services that do not require a license and assist Members with connecting to appropriate services to improve their health.

  • Assist Members 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.

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

 

  • Available to Members who meet any of the following circumstances as determined by a licensed practitioner:
    • The Member has been violently injured because of community violence.
    • The Member is at significant risk of experiencing violent injury because of community violence.
    • The Member has experienced chronic exposure to community violence.

Eligibility Criteria for Community Health Worker Services

 

To be eligible for CHW services one or more of the following must be met: 

 

  • Members experiencing one or more chronic conditions (including behavioral health)
  • Exposure to violence/trauma
  • At risk for chronic health condition or environmental health exposure
  • Face barriers meeting their health or health related social needs
  • One or more visits to a hospital emergency department within the previous six months.
  • One or more hospital inpatient stays (including psychiatric facilities) within the previous six months. 
  • One or more stays at a detox facility within the previous year. 
  • Two or more missed medical appointments within the previous six months. 
  • Would benefit from preventive services
  • Member expressed need for support in health system navigation or resource coordination services.

 

 

Documentation Requirements:

 

  • Written recommendation by Provider to initiate CHW benefit
  • First 12 units of CHW services do not require prior authorization
  • Service dates, time/duration, and nature of service provided
  • Plan of Care and authorization are required after completing 12 units of care annually
  • DISCLAIMER: for CHW services provided in the Emergency Room no prior authorization is needed. 

Community Health Worker

A CHW is a frontline public health worker who is a trusted member or has a good understanding of the community served.

 

The role of the CHW is to provide the following:

  • Serve as liaison between health/social services systems and the community.
  • Facilitate access to services and improve the quality and cultural competence of service delivery. 
  • Build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. 

 

Community Health Worker Minimum Qualifications:

  • Must have lived Experience
  • One of the following certificates:
    • CHW Certificate – issued by State or California or designee
    • Violence Prevention Certificate
  • Work Experience Pathway – 2,000 hours as a CHW in last three years (paid or volunteer)
    • May provide CHW services without a certification of completion for a maximum period of 18 months.
  • Continuing Education – must maintain a minimum of six hours per year of additional relevant training.

Claims, Billing and Payments for Community Health Services

Services must be reimbursed by a Medi-Cal enrolled CHW supervising Provider in accordance with their Provider contract. 

  • Claims for CHW services must be submitted by the Supervising Provider with allowable current procedural terminology codes as outlined in the Medi-Cal Provider Manual. 
  • Providers shall not submit for duplicative services (i.e. claims for CHW and Enhanced Care Management services) 

 

 

CHW Supervisor Requirements:

  • A supervising Provider is the organization employing or otherwise overseeing the CHW with which the Managed Care Plan contracts.
  • The supervising Provider must be one of the following: 
    • A licensed Provider
    • Hospital
    • An outpatient clinic
    • A local health jurisdiction (LHJ) or a community-based organization (CBO)

 

For further Information about the CHW Supervisor Requirements:

Provider Enrollment and Implementation of Services

IEHP network Providers, including those who will operate as supervising Providers of CHW services, are required to enroll as Medi-Cal Providers first, consistent with APL 22-013 (Provider Credentialing/Re-credentialing and Screening/Enrollment), or any superseding APL, if there is a state-level enrollment pathway for Providers to do so.

  

For existing IEHP Providers who qualify, are interested in the CHW Benefit, or would like to know how to get started email questions to chwbenefit@iehp.org.

 

In addition, you can also fill out and submit the following CHW Benefit Implementation Readiness Survey to help us evaluate your organization’s capacity to use this benefit:

Supplemental Support and Other Resources

For a limited time, IEHP is offering an incentive to qualifying Providers to support the first few months of CHW costs until there is a process in place to bill for sustainability. For information related to the application process or the CHW Provider Incentive Program email questions to chw@iehp.org.

The IEHP CHW Certificate Training Program is a two week in-person training conducted at the IEHP Dr. Bradley P. Gilbert Center for Learning and Development. 

 

For IEHP Providers who are interested in the CHW Certificate Training Program, the FAQ provides additional information and a survey to complete. Please note, to be eligible for this training opportunity Providers must be engaged in the CHW contracting process with IEHP.

Supervisor Provider Training will be assigned once a CHW contract is executed. For additional information or questions email chwbenefit@iehp.org.

 

Topics covered in the CHW Supervisor Training include:

 

  • CHW Scope of Work
  • Covered Services
  • Non-Covered Service
  • CHW Qualifications
  • Member Eligibility
  • Department of Health Care Services (DHCS) Goals and Strategy
  • Supervising Provider Role and Responsibilities 
  • Documentation
  • Recommendation and Claims Process