Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and program under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law sets forth a schedule of covered benefits under the Medi-Cal program, which includes community health worker services.

Existing law defines community health worker as a liaison, link, or intermediary between health and social services and the community to facilitate access to services and to improve the access and cultural competence of service delivery and who is a frontline health worker either trusted by, or who has a close understanding of, the community served. Existing law includes in the definition of community health worker Promotores, Promotores de Salud, Community Health Representatives, navigators, and other nonlicensed health workers with specified qualifications.

This bill would require the department to, department, by no later than January 1, 2026, 2025, and until December 31, 2026, to convene the Promotores and Promotoras Advisory and Oversight Workgroup to examine the implementation of the community health worker benefit under provide perspective and guidance to changes in the health and human services delivery system, including, but not limited to, the Medi-Cal program. The bill would require the director secretary to appoint no fewer than 9 individuals to the workgroup who have at least ten years experience working in California as, or with, Promotores. Promotores or Promotoras. The bill would require the workgroup to be comprised of no less than 51% Promotores, Promotores or Promotoras, as specified, and require the appointees to be from geographically diverse areas of the state. The bill would require the workgroup to advise the department departments under the agency to ensure that community health worker services are available to all eligible Medi-Cal beneficiaries who want those services, services provided by Promotores or Promotoras are available and accessible to all eligible populations. The bill would also require the workgroup to advise the agency to ensure that community health worker Promotores and Promotoras training and outreach materials are culturally and linguistically appropriate, to make recommendations on outreach efforts, as specified, and to provide input on issues that should be informed by community representatives who have lived experience with using and navigating Promotores or Promotoras services and the Medi-Cal program.

Existing law requires the Department of Health Care Access and Information to, on or before July 1, 2023, develop statewide requirements for community health worker certificate programs in consultation with stakeholders, including, but not limited to, the State Department of Health Care Services, the State Department of Public Health, community health workers, Promotores and Promotores de Salud, or representative organizations. Existing law defines community health worker as, among other things, a liaison, link, or intermediary between health and social services and the community to facilitate access to services and to improve the access and cultural competence of service delivery.

This bill would state the intent of the Legislature to enact legislation related to community health workers.

Date of Hearing: May 8, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 3149

Author:(Garcia) – As Amended Ver:April 18, 2024

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Health and Human Services Agency (CalHHS) to convene the Promotores and Promotoras Advisory and Oversight Workgroup (workgroup) to provide perspective and guidance to changes in the health and human services delivery system.

Specifically, this bill:

1. Requires the workgroup to be convened by January 1, 2025, and until December 31, 2026.
   
2. Specifies the makeup of the workgroup to include at least 51% promotores or promotoras, among other criteria.
   
3. Specifies the duties of the workgroup, including advising on access to community health worker (CHW) services, cultural and linguistic appropriateness of training and outreach materials, outreach and awareness efforts, and providing input on other issues based on the workgroup members’ lived experience.

FISCAL EFFECT:

Costs to CalHHS of $319,000 for fiscal year (FY) 2024-25 and $332,000 for FY 2025-26 and FY 2026-27 for two positions and contracting costs to convene the workgroup by January 1, 2025 (General Fund).

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years.

COMMENTS:

1. Purpose. Visión y Compromiso is the sponsor of this bill. According to the author:

Promotoras, as included under the state’s definition of Community Health Workers, are a predominantly women-led Latina workforce, working with low-income and traditionally underserved communities to provide reliable information, connections to resources, public health, social services, education, housing, and legal systems. They provide effective connections to components recognized as social determinants of health. Promotoras are trusted community ambassadors serving as vital resource links between our most vulnerable populations and traditional health systems to improve health outcomes. As California embarks on the important work to include Community Health Worker, Promotora, and Representatives as a Medi-Cal benefit and augment the workforce, we must integrate the voices and feedback of promotoras, our on the ground community health leaders, in the planning and decision-making.

1. Background.

CHWs in Medi-Cal. As of July 1, 2022, over half of states reported allowing Medicaid payment for services provided by CHWs. The Department of Health Care Services (DHCS) engaged stakeholders and experts on Medicaid coverage of CHW services in other states to inform policy and implementation of Medi-Cal’s CHW benefit. DHCS added CHW services, including violence prevention services, as a Medi-Cal benefit starting July 1, 2022. The benefit was codified through AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022. CHW services are defined to include those delivered by promotores, community health representatives (CHRs; professionals who work in a tribal setting), navigators, and other non-licensed health workers.

Department of Health Care Access and Information (HCAI) CHW Workforce Effort. The Budget Act of 2022 included approximately $281.4 million over three years to support a new program to recruit, train, and certify 25,000 new CHWs by 2025. According to HCAI, the training requirements would align with Medi-Cal requirements for reimbursement. Although most of the funding has been delayed until FYs 2024-25 and 2025-26 fiscal years, the multi-year amount in the Governor’s FY 2024-25 budget is still the same as originally proposed.

1. Implementation Concern. HCAI notes that if CalHHS delegated the implementation of this bill to HCAI, HCAI would not be able to request resources in time for a January 1, 2025 implementation.
2. Related Legislation.
   1. AB 2250 (Weber) requires Medi-Cal and commercial health plans and insurers to cover social determinants of health screenings, and requires commercial health plans and insurers to provide to physicians who provide primary care services with adequate access to peer support specialists, lay health workers, social workers, or CHWs. AB 2250 is pending in this committee.
   2. AB 85 (Weber), of the current legislative session, was similar to AB 2250 (Weber) and was vetoed by Governor Newsom, who stated it was premature and duplicative of existing efforts.
3. Prior Legislation.
   1. AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022, codifies CHW services as a covered Medi-Cal benefit.
   2. SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, the 2022 Health Trailer Bill, requires HCAI to develop statewide requirements for CHW certificate programs in consultation with stakeholders.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 16, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 3149

Author:((Garcia) – As Amended Ver:March 18, 2024

SUBJECT: Promotores Advisory and Oversight Workgroup.

SUMMARY: Requires the Department of Health Care Services (DHCS) to convene the Promotores Advisory and Oversight Workgroup (workgroup) to examine the implementation of the community health worker (CHW) benefit under the Medi-Cal program. Specifically, this bill:

1. Requires the workgroup to be convened by January 1, 2026, and until December 31, 2026.
   
2. Specifies the makeup of the workgroup, including no less than 51% promotores, including, but not limited to, a representative from a statewide network of promotores and community health workers, a representative from a community-based organization, a representative from a health clinic or community health center, and a representative from a regional organization.
   
3. Specifies the duties of the workgroup, including advising on access to CHW services, cultural and linguistic appropriateness of training and outreach materials, outreach and awareness efforts, and providing input on other issues based on the workgroup members’ lived experience.
   

EXISTING LAW:

1. Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) §14000 et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program. [WIC §14132]
3. Establishes CHW services as a Medi-Cal benefit and requires DHCS, through existing and regular stakeholder processes, to inform stakeholders about, and accept input from stakeholders on, implementation of the CHW services benefit. [WIC §14132.36]
4. Defines CHW to mean a liaison, link, or intermediary between health and social services and the community to facilitate access to services and to improve the access and cultural competence of service delivery. States that CHWs include Promotores, Promotores de Salud, community health representatives, navigators, and other nonlicensed health workers, including violence prevention professionals. Requires a CHW’s lived experience to align with and provide a connection to the community being served. [WIC § 18998]
   
5. Requires DHCS to convene a workgroup to examine the implementation of the Medi-Cal doula benefit and to, by July 1, 2025, publish a report on utilization of the benefit that identifies any barriers that impede access to doula services and make recommendations to reduce any identified barriers. [WIC §14132.24]
6. Requires the Department of Health Care Access and Information (HCAI) to develop statewide requirements for CHW certificate programs in consultation with stakeholders. [WIC § 18998.1, et seq.]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, promotoras, as included under the state’s definition of CHWs, are a predominantly women-led Latina workforce, working with low-income and traditionally underserved communities to provide reliable information, connections to resources, public health, social services, education, housing, and legal systems. The author notes they provide effective connections to components recognized as social determinants of health, and promatoras are trusted community ambassadors serving as vital resource links between our most vulnerable populations and traditional health systems to improve health outcomes. The author concludes that as California embarks on the important work to include Community Health Worker, Promotora, and Representatives (CHW/P/R) as a Medi-Cal benefit and augment the workforce, we must integrate the voices and feedback of promotoras, our on the ground community health leaders, in the planning and decision-making.
2. BACKGROUND.
   1. CHW Services. As of July 1, 2022, over half of states (29 of 48) reported allowing Medicaid payment for services provided by CHWs. DHCS engaged with stakeholders and experts on Medicaid coverage of CHW services in other states to inform policy and implementation of the CHW benefit. DHCS added CHW services, including violence prevention services, as a Medi-Cal benefit starting July 1, 2022. The benefit was codified through AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022. CHW services are defined to include those delivered by promotores, community health representatives (CHRs; professionals who work in a tribal setting), navigators, and other non-licensed public health workers.
      1. General Rules. CHW services are defined in Medi-Cal under federal regulations on “preventive services,” and must therefore be recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under state law. In addition to physicians, a range of non-physician medical practitioners and behavioral health professionals can recommend CHW services. The recommending provider does not need to be enrolled in Medi-Cal or be a network provider for the Medi-Cal member’s managed care plan. Medical necessity for services is defined fairly broadly—individuals are eligible for services if they have one or more chronic conditions, have a behavioral health diagnosis or suspected behavioral health condition, have visited a hospital emergency department or had an inpatient stay within the prior six months, express need for support in health system navigation or resource coordination, or meet at least one of a number of other criteria. To provide more than 12 units (six hours) of CHW services for an individual, the services must be provided pursuant to a written plan of care. Services can be provided in an individual or group setting, and can be provided virtually. There are no restrictions as to where services can be delivered. The federally approved State Plan Amendment19 for CHW services describes the services and qualifications, and the Medi-Cal Provider Manual for CHW services further describes billing procedures, policies, and supervision of CHWs.
         
         The supervising provider, who submits claims for services, is an enrolled Medi-Cal provider who oversees the services provided and ensures a CHW meets the defined qualifications. The supervising provider can be a licensed provider, a hospital, an outpatient clinic, a local health jurisdiction (LHJ), or a community-based organization (CBO). CHWs may be supervised by a CBO or LHJ that does not have a licensed provider on staff.
      2. Health Topics Addressed. CHWs can address issues that include but are not limited to control and prevention of chronic conditions or infectious diseases; mental health conditions and substance use disorders; perinatal health conditions; sexual and reproductive health; environmental and climate-sensitive health issues; child health and development; oral health; aging; injury; domestic violence; and, violence prevention.
      3. Definition of Services. Medi-Cal defines CHW services as including health education; navigation to health care and other community resources that address health-related social needs; screening and assessment to identify the need for services; and individual support and advocacy that assists a beneficiary in preventing a health condition, injury, or violence.
   2. CHW Benefit Utilization and Expenditure Data. As of July 1, 2022, CHW services have been a covered benefit in Medi-Cal Fee-for-Service (FFS) and managed care. The 2023 Budget and the 2024-25 Governor’s Budget each assume total annual Medi-Cal expenditures of $91.9 million for the CHW benefit ($82.7 million in managed care and $9.2 million in FFS).
      
      Costs associated with CHW services are reflected in managed care rates as of January 1, 2023; however, billing data shows little utilization. Actual data on CHW visits billed to Medi-Cal through FFS and managed care through January 25, 2024, have not exceeded $1 million. These data only include CHW services that were individually billed through the CHW benefit. CHW services are also billed in other ways, so these data also exclude other important avenues through which CHW services may be delivered in Medi-Cal, such as though DHCS initiatives called Enhanced Care Management and Community Supports. Services provided at federally qualified health centers (FQHCs) and rural health centers (RHCs) are also not included; based on nuances of the way these clinics bill Medi-Cal, FQHCs and RHCs cannot directly bill for CHW services.
      
      Budget estimates for new benefits, particularly when provided by non-traditional providers, are often uncertain and a ramp-up period is expected. Although the data show thousands of Medi-Cal members have received CHW services through the CHW benefit, given the size of the Medi-Cal population and the potential to deploy CHWs in many different areas to meet health and health-related social needs, it is apparent that the rollout of the CHW benefit has been slower than anticipated.
      
      DHCS has taken a number of actions to describe expectations for coverage and provision of the CHW benefit, as well as planned monitoring, including guidance to managed care plans, requiring plans to describe how they will integrate CHWs, creating a new enrollment pathway for community-based organizations and local health jurisdictions, basing incentive payments to plans on utilization of CHW services, adding CHW services to the Medi-Cal dental program to address oral health, and monitoring the provision of CHW services through another initiative called “Population Health Monitoring.”
   3. HCAI CHW Workforce Effort. The 2022 Budget Act included approximately $281.4 million over three years to support a new program to recruit, train, and certify 25,000 new CHWs by 2025, including those with specialized training to work with specific populations or on specific issues. According to HCAI, the training requirements would align with Medi-Cal requirements for reimbursement. Although most of the funding has been delayed until the 2024-25 and 2025-26 fiscal years, the multi-year amount in the 2024 Governor’s Budget is still the same as originally proposed.
      
      SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, the 2022 Health Trailer Bill, required HCAI to develop statewide requirements for CHW certificate programs in consultation with stakeholders. . In July 2023, following a series of stakeholder consultation sessions, HCAI issued a guidance letter implementing the requirements. However, the guidance letter has since been “paused,” pending additional stakeholder engagement.
      
      HCAI also notes it is working closely with DHCS to align pathways and eventually consolidate into one state certificate process for CHW/P/Rs.
   4. HCAI’s Stakeholder Engagement.
      
      1. Initial Stakeholder Work: To inform the development of the July 2023 guidance letter, HCAI conducted 43 stakeholder sessions with a total attendance of 1,573 across all sessions. HCAI developed the certificate model through three iterative models in response to stakeholder feedback. HCAI shared each certificate model iteration in draft form during information sessions and solicited suggestions for improvement. HCAI conducted sessions in Spanish and offered Spanish language translation services during English sessions. Written feedback from stakeholders was also encouraged, and HCAI received written comments in both English and Spanish. HCAI offered to provide translation and interpretation services in other languages upon request.
         
      2. Current Work: The state team comprised of California Health and Human Services Agency (CHHSA), DHCS, and HCAI launched a further stakeholder engagement process in February 2024, with work planned to conclude in June 2024. The agencies first convened an ad hoc advisory group comprised of a number of key organizations and thought leaders in the CHW/P/R space. This group advised on the dialogue guide, process, and site selection for stakeholder input and will continue to advise to ensure the process is comprehensive, relevant, and appropriate. The goal of this stakeholder effort is to get feedback on what is working well and what are the barriers to expanding the CHW/P/R workforce, how HCAI can best use its funds for recruiting, training, and certifying CHW/P/Rs, and the value, risks, scope, and unintended consequences of a statewide certificate.
         
         HCAI indicates the intent is to conduct approximately 20 stakeholder dialogues from February to June 2024, with dialogues appropriately distributed by geography and also covering the wide range of populations that CHW/P/Rs serve. Once the stakeholder process has concluded, HCAI plans to finalize funding priorities with input from the ad hoc advisory group, with the aim of launching grants and contracts reflecting these priorities in early 2025. The first dialogue was held on February 24th, 2024, at La Clinica de la Raza in Oakland. Subsequent sessions are being scheduled with a list of host sites selected to maximize geographic distribution and population representation.
   5. Assembly Informational Hearing. On March 12, 2024, the Assembly Committee on Health and Budget Subcommittee No.1 on Health held an informational hearing on implementation of the Medi-Cal CHW benefit and the CHW/P/R workforce efforts within HCAI. It noted both initiatives are still in the early stages of implementation, and although there is significant excitement about these investments and the potential of both initiatives, and a number of promising developments, a diverse array of stakeholders have noted various barriers to implementing these efforts and to expanding CHW/P/R workforce and services generally. The hearing provided background on CHW/P/Rs and recent state efforts, and documented and discussed both bright spots and challenges in implementation of these state initiatives and broader deployment of CHWs.

Bright spots include having the “policy infrastructure” in place for Medi-Cal financing of CHW services, the responsiveness of the state to stakeholder input, the availability of CHW training programs in California, statewide and regional collaboratives to promote CHWs, capacity-building investments at DHCS, and federal funding and attention.

Challenges and barriers include limited administrative infrastructure for community-based organizations and other small, community-based potential providers of CHW services; a constrained workforce; ongoing financial sustainability, including inadequacy of rates, the inability of FQHCs and RHCs to directly bill for services, and little public health funding for CHWs; disagreement among stakeholders about the purpose and value of certification; a lack of ongoing support for promoting best practices; training “deserts” throughout the state, such as the rural north; and the dual roles CHWs occupy, as embedded in and advocates for their community as well as part of the “professional culture” of health care.

Based on the findings of the hearing, the successful expansion and integration of CHW services through the Medi-Cal CHW benefit has the potential to be transformative, but there are many implementation hurdles to address that will require significant dialogue and partnership among many stakeholders.

• 1. Doula Benefit Implementation Workgroup. Medi-Cal added doula services as a covered benefit effective January 1, 2023. DHCS convened an ad hoc advisory workgroup of doulas and other interested parties to advise DHCS on the development of the doula benefit, similar the CHW-specific workgroup convened to advise on the development of the CHW benefit.
     
     The CHW benefit and doula benefit are similar in that they were both recently added as preventive services to improve health outcomes and health equity in Medi-Cal; the qualifications of both types of nonclinical personnel are defined through the Medi-Cal benefit for purposes of the program, because no external certification standards exist; and the initial rollout of both efforts have been challenged by inadequate workforce and concerns regarding low reimbursement by providers. However, DHCS has since significantly increased rates for doula services and proposed additional rate increases for these services, and pursuant to SB 65 (Skinner), Chapter 449, Statutes of 2021, DHCS is convening an additional time-limited workgroup to examine and advise on implementation of the doula benefit.
     
     The Doula Implementation Workgroup is comprised of 30 members. Meetings are quarterly, facilitated by an expert organization that helps government agencies center equity in their work and strengthen their cultural responsiveness. Per SB 65, the workgroup addresses access to doula services, outreach efforts, minimizing barriers and delays in payments, and helping to inform DHCS’s legislative report due July 1, 2025.

This bill would implement a similar, time-limited committee to oversee and advise on implementation of the CHW benefit.

1. SUPPORT. Supporters, including California Pan - Ethnic Health Network, Latino Coalition for a Healthy California, numerous individual promotoras and others, note the importance of including voices of historically marginalized communities in decisions that impact their health and wellness, including the availability of and cultural and linguistic relevance of CHW/P/R services.
2. RELATED LEGISLATION. AB 2250 (Weber) requires commercial health plans and insurers, as well as Medi-Cal, to provide cover social determinants of health screenings, and requires commercial health plans and insurers to provide to physicians who provide primary care services with adequate access to peer support specialists, lay health workers, social workers, or CHWs, as defined. AB 2250 passed the Assembly Health Committee on April 2, 2024, on a 15-0 vote and is pending in the Assembly Appropriations Committee.
3. PREVIOUS LEGISLATION.
   1. AB 85 (Weber) of 2023 was similar to AB 2250 (Weber) and was vetoed by Governor Newsom, who said it was premature and duplicative of existing efforts.
   2. AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022, codifies CHW services as a covered Medi-Cal benefit.
   3. SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, the 2022 Health Trailer Bill, codified the HCAI workforce initiative.
   4. SB 65 enacts programs aimed at improving maternal health and required DHCS to convene a workgroup no later than April 1, 2022, and until December 31, 2023 to examine the implementation of the Medi-Cal doula benefit and submit a report. AB 118 (Committee on Budget), Chapter 42, Statutes of 2023, subsequently extended the workgroup until June 30, 2025.
4. AMENDMENTS. Based on discussion between the author, sponsor and Committee regarding the ability of promotoras to engage on a broader range of issues under consideration by state health agencies, the author and Committee have agreed to amend this bill to broaden the scope of the workgroup beyond the CHW benefit to other relevant initiatives under CHHSA and move the workgroup under the auspices of CHHSA. The author and Committee have also agreed to amend the bill to use the term “promotoras,” in addition to promotores, to recognize the role and emphasize the voices of promotoras.

REGISTERED SUPPORT / OPPOSITION:

Support

Visión Y Compromiso (sponsor)

California Pan - Ethnic Health Network

Centro La Familia Advocacy Services

Latino Coalition for a Healthy California

Sierra Community House

A large number of individuals who identify as promotoras

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097