New and updated programs within the California Department of Health Care Services (DHCS) under the California Advancing and Innovating Medi-Cal, or CalAIM initiative focus on transforming the state’s Medicaid program, and with it, the care that millions of Medi-Cal beneficiaries receive.
Several significant changes introduced within CalAIM create opportunities for traditionally revenue-tight community-based organizations (CBOs) to create an income stream to sustain their operations while expanding their care capabilities. Namely, Enhanced Care Management (ECM), Community Supports (CS), and the Community Health Worker (CHW) benefit.
Although a Medi-Cal beneficiary may qualify for multiple services, a community-based provider cannot bill all three benefits—ECM, CHW, and CS—for the same client. For example, while a member can be enrolled in both ECM and CS or CHW and CS, they cannot receive both ECM and CHW support simultaneously. An organization may serve as an ECM, CHW, and CS provider, but must adhere to these billing restrictions.
Curious if your CBO qualifies for any of these reimbursement opportunities? Let’s dive into the nuances of these CalAIM incentives and determine which might be right for your CBO to utilize.
What is the Medi-Cal benefit for Community Health Workers?
Recognizing the role of community health workers (CHWs) in delivering services to improve whole-person care by addressing clients’ social and health needs, the California Department of Health Services (DHCS) made CHW services delivered to Medi-Cal members reimbursable in 2022.
The community health worker benefit is the most universal in terms of who qualifies to receive CHW services and which organizations may be able to bill for these services.
It recognizes CHWs as a new individual provider type and allows community-based organizations, which often employ CHWs, care coordinators, navigators, promotores, and volunteers, to serve as a billing and supervising provider. Additionally, the eligibility criteria to receive CHW services are broad in scope, and any Medi-Cal member with a health or social need qualifies.
Under the state plan, Medi-Cal reimburses for CHW services, including:
- Health education and promotion (e.g., teaching disease prevention or healthy behaviors or explaining health services, such as counseling or therapy)
- Health system navigation and advocacy (e.g., helping beneficiaries understand and access care and services, such as housing assistance)
- Formal and informal screenings and assessments for preventive care needs
- Violence prevention, asthma management, and other specialized preventive services
What it looks like
A family that has Medi-Cal insurance by a local Managed Care Plan (MCP) attends a local community farmer’s market where a community-based organization is providing back-to-school supplies and healthy snacks to children who stop at their booth.
A community health worker chats with the parents, and after some discussion discovers that the children in the family haven’t visited a medical provider in several years. Typically, they only access urgent care when they’re sick. The CHW completes a health screening and provides information about a pop-up vaccination clinic later that week. The CHW collects their information and can bill for the services provided to them that day, as well as in the future when follow-up navigation is provided. Additionally, any other Medi-Cal members who stop by the booth and receive CHW services during the event may also be eligible for billable services.
What is the Enhanced Care Management (ECM) program?
The ECM program aims to transform the administration of Medi-Cal while improving health outcomes by coordinating services across physical health, behavioral health, and social services. It’s a whole-person care model, designed to provide comprehensive, person-centered care management for Medi-Cal beneficiaries with complex medical and social needs.
Unlike services that qualify for reimbursement through the CHW benefit, the ECM program and services target specific populations with complex health challenges.
ECM targets Medi-Cal beneficiaries who fit into one of the Populations of Focus (POF):
- Individuals and families experiencing homelessness
- Adults and children with serious mental health and/or substance use disorders
- Adults at risk for avoidable hospital or emergency department utilization
- Adults and children at risk of institutionalization and eligible for long-term care services
- Nursing facility residents transitioning to the community
- Individuals transitioning from incarceration
- Pregnant and postpartum individuals
- Children and youth with complex physical, behavioral, or developmental needs
And who may require services, most of which are delivered by a Lead Care Manager (LCM), including:
- Outreach and engagement, which may or may not be provided by a CHW
- Comprehensive assessment and care management planning
- Enhanced coordination of care among healthcare providers
- Health promotion and coaching
- Comprehensive transitional care
- Member and family support services
- Coordination and referral to community and social support services
By integrating and coordinating care across various sectors, the ECM program addresses the holistic needs of Medi-Cal beneficiaries, ultimately leading to improved health outcomes, and reduced healthcare costs.
What it looks like
A homeless individual has a chronic and unmanaged condition, such as diabetes. Their lack of housing qualifies them for ECM services. An LCM is assigned, either by referral from the managed care plan or an existing provider relationship, and they become the primary point of contact to coordinate healthcare services for the client. This includes working with the client’s medical provider for their diabetes care plan and other health-related challenges, such as behavioral health or substance misuse support. To help the client find stable housing, the ECM provider would refer the client to a housing partner or address the need within their organization, if they have experience.
In this instance, the case management services provided qualify for reimbursement under the ECM initiative. The additional support to address social needs, including housing or transportation and food services, if needed, may also qualify for reimbursement through the community supports (CS) program.
What is the Community Supports (CS) program?
The CS program is intended to address a Medi-Cal member’s health-related social needs, helping them avoid higher, costlier levels of care.
Similar to ECM, clients must qualify for CS services by receiving a referral, which means that the MCP determines that the CS services are medically necessary and more cost-effective in meeting the client’s needs than their existing care plan.
Under the state plan, community supports services include:
- Housing transition navigation services
- Housing deposits
- Housing tenancy and sustaining services
- Short-term post-hospitalization housing
- Recuperative care
- Respite services, or short-term relief to primary caregivers of adults or children
- Day habilitation programs
- Nursing facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Facilities for the Elderly (RCFE) and Adult Residential Facilities (ARF)
- Community transition services or nursing facility transition to a home
- Personal care and homemaker services
- Environmental accessibility adaptations or home modifications
- Medically supportive food or meal support, such as providing medically tailored meals
- Sobering centers
- Asthma remediation
At a glance: Enhanced care management, community supports, and community health worker services
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Together, these programs can complement one another, addressing different aspects of health and social care for Medi-Cal beneficiaries.
What CalAIM program is best for your organization?
The most appropriate benefit depends primarily on the population your organization serves and the interest and readiness of your programs team.
Community Health Worker (CHW) benefit
This is a great starting point for CBOs already providing the services covered under the CHW benefit. It’s simple to start because there are fewer compliance requirements, no population limitations—a client only needs to qualify for Medi-Cal—and the services are typically those aimed at addressing social drivers of health, and not complex health conditions, and much flexibility with program design
The billing is also straightforward with three defined CPT codes.
Enhanced Care Management services reimbursement
Organizations that already work with and successfully support high-risk populations can benefit from the higher reimbursement for ECM services; however, the requirements for compliance, care coordination, and billing are more complicated.
For instance, many MCOs require ECM providers to be able to refer to a provider for medical reconciliations, have partnerships with clinical organizations, and have the infrastructure to meet complex reporting and billing requirements. Certainly, having a system, like Pear Suite’s care navigation platform, to document and bill for their activities, can help.
Often, CBOs will get started with CalAIM by utilizing Medi-Cal’s CHW benefit and then will step up to ECM service reimbursement when all the required relationships and systems are in place, and staff are comfortable advancing.
Community supports services reimbursement
Like ECM, CBOs need to have experience working with higher-risk populations. However, because community support services focus on specialized social needs rather than broader needs, the additional billing complexities may be more straightforward.
A CBO that provides CS services, such as housing support, for example, may also be able to provide CS services to ECM clients.
Billing for CalAIM services provided to Medi-Cal members
Even with detailed guidance and the promise of additional revenue, ECM, CS, and CHW providers often struggle to kickstart these programs due to policy, compliance, technology, or other competency gaps.
This is where Pear Suite comes in and supports providers and organizations across any of these services.
Through our care navigation and billing platform, community-based providers can track and manage services provided to eligible Medi-Cal clients and securely submit claims with managed care plans. Providers and organizations also have the option to join Pear Suite’s hub of community providers, simplifying access to reimbursement without having to navigate the application and contracting process to become an in-network health plan provider on their own.
