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Community Health Worker Services

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Community Health Worker (CHW) services assist members with accessing preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and promote physical and mental health and wellbeing.

CHWs may include individuals known by a variety of job titles, such as community health representatives, navigators, promotors, and other non-licensed public health workers, including violence prevention professionals.

Eligibility requirements

The Department of Health Care Services (DHCS) issued a statewide standing recommendation that all Medi-Cal members who meet the defined eligibility criteria for receiving CHW services would benefit from CHW services. This recommendation fulfills the federal requirements in section 440.130(c) of title 42 of the Code of Federal Regulations for a physician or other licensed practitioner of the health arts acting within their scope of practice to provide a written recommendation for preventive services. CHWs who use this standing recommendation for Medi-Cal members should note the standing recommendation and the member's eligibility criteria in their records.

CHW services can be provided as individual or group sessions. The services can also be provided virtually or in-person with locations in any setting including, but not limited to, outpatient clinics, hospitals, homes, or community settings. There are no service location limits. Supervising providers should refer to the Provider Manual for guidance regarding telehealth.

Services include:

  • Health education: Promote the member’s health or address barriers to physical and mental health care, such as providing information or instruction on health topics. Health education content must be consistent with established or recognized health care standards and may include coaching and goal setting to improve the member’s health or ability to self-manage their health conditions.
  • Health navigation: Provide information, training, referrals, or support to help members access health care, understand the health care delivery system, or engage in their own care. This includes connecting members to community resources necessary to promote health; address barriers to care, including connecting to medical translation/interpretation or transportation services; or addressing health-related social needs. CHWs can also:

    • Serve as a cultural liaison or assist a licensed health care provider to participate in the development of a plan of care, as part of a health care team;

    • Perform outreach and resource coordination to encourage and facilitate the use of appropriate preventive services; or

    • Help the member 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: Provide screening and assessment services that do not require a license and assist members with connecting to appropriate services to improve their health.
  • Individual support or advocacy: Assists Medi-Cal 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.

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

Below are member eligibility criteria to qualify for CHW services:

  • Currently enrolled in Medi-Cal.
  • Diagnosed with one or more chronic physical or behavioral health conditions or suspected of having a mental health or substance use disorder.
  • Rising risk of chronic disease, as shown by medical indicators (e.g., elevated blood pressure or glucose levels), but do not yet warrant diagnosis of a chronic condition.
  • Have experienced a stressful life event identified through Adverse Childhood Experiences (ACEs) screening.
  • Exhibit known risk factors such as domestic violence, intimate partner violence, tobacco use, excessive alcohol consumption, or drug misuse.
  • Screened positive for unmet health-related social needs (e.g., housing or food insecurity).
  • Had one or more emergency department visits in the past six months.
  • Had one or more inpatient hospital stays (including psychiatric facilities) within the past six months or are at risk of institutionalization.
  • Had a stay at a detoxification facility within the past year.
  • Missed two or more medical appointments in the past six months.
  • Expressed a need for help navigating the health system or coordinating resources.
  • Requires preventive services such as immunizations, dental visits, or well-childcare visits.

Reimbursement

This standing recommendation authorizes CHWs to provide covered Medi-Cal CHW services including health education, health navigation, screening and assessment, and individual support and advocacy, which can be reimbursed using established current procedural terminology (CPT) billing codes noted in your contract.

Ongoing and extended services

Licensed providers are encouraged to develop a written plan of care when a need for multiple or ongoing CHW services is identified, and a written plan of care is required for continued CHW services after 12 units of care per Medi-Cal member in a single year from the initial date of service, which would constitute a new recommendation for more than the six hours authorized by the standing recommendation.

Member Access to CHW Services

Eligible Medi-Cal members can directly access CHW services by:

1. Member Services (Anyone can make a referral)

2. Provider Directory (Anyone can make a referral)

Go to the CalAIM Resources for Providers page to learn more about CHW and its in-depth workflow.

Member Resources

Refer to the below for more information on CHW:

Reference:

Community Health Worker (CHW) Preventive Services Provider Manual (PDF)

Last Updated: 09/29/2025