Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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.

Under existing law, community health worker (CHW) services are a covered Medi-Cal benefit subject to any necessary federal approvals. CHW is defined 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. Existing law requires a Medi-Cal managed care plan to engage in outreach and education efforts to enrollees with regard to the CHW services benefit, as specified. Existing law requires the department to inform stakeholders about implementation of the benefit.

This bill would require the department to annually review the above-described outreach and education efforts conducted by Medi-Cal managed care plans. The bill would require the department to annually conduct an analysis of the CHW services benefit, submit each the analysis to the Legislature, and publish each the analysis on the departments internet website, with the first analysis due July 1, 2027.

The bill would require the analysis to include, at a minimum, an assessment of CHW capacity and the needs of Medi-Cal beneficiaries, a disaggregation of the assessment by geographic region, race, ethnicity, language, age, and other sociodemographic factors, and by Medi-Cal managed care plan as applicable, the above-described outreach and education efforts conducted by each Medi-Cal managed care plan, an assessment of the CHW benefit utilization and services, a demographic disaggregation of CHWs providing the CHW benefit and the Medi-Cal beneficiaries receiving services, and data on Medi-Cal reimbursements for CHW services billed to the department, as specified.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and 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.

Under existing law, community health worker (CHW) services are a covered Medi-Cal benefit subject to any necessary federal approvals. CHW is defined 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. Existing law requires a Medi-Cal managed care plan to engage in outreach and education efforts to enrollees with regard to the CHW services benefit, as specified. Existing law requires the department to inform stakeholders about implementation of the benefit.

This bill would require the department to annually review the above-described outreach and education efforts conducted by Medi-Cal managed care plans. The bill would require the department to annually conduct an analysis of the CHW services benefit, submit each analysis to the Legislature, and publish each analysis on the departments internet website, with the first analysis due July 1, 2027.

The bill would require the analysis to include, at a minimum, an assessment of CHW capacity and the needs of Medi-Cal beneficiaries, a disaggregation of the assessment by geographic region, race, ethnicity, language, age, and other sociodemographic factors, and by Medi-Cal managed care plan as applicable, and data on Medi-Cal reimbursements for CHW services billed to the department, as specified.

Date of Hearing: April 9, 2025

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 403

Author:(Ortega) – As Amended Ver:March 17, 2025

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

SUMMARY:

This bill requires the Department of Health Care Services (DHCS) to analyze the community health workers (CHW) benefit in the Medi-Cal program and publish the analysis on the DHCS website annually, with the first analysis due July 1, 2027.

The bill requires the analysis to include the following:

1. An assessment of each Medi-Cal managed care plan’s outreach and education efforts.
2. An assessment of the CHW benefit utilization and services provided to Medi-Cal beneficiaries in Medi-Cal managed care plans or the fee-for-service delivery system, including demographic disaggregation of CHWs and the beneficiaries receiving CHW services, frequency of each service provided by CHWs, number of referrals by provider type, estimate of the number of eligible Medi-Cal beneficiaries, number of CHWs by employer type, expected demand for CHW services, and data on reimbursements for CHW services.

FISCAL EFFECT:

General Fund costs of an unknown amount, likely exceeding $150,000 annually, for DHCS to conduct and publish the analysis.

COMMENTS:

1. Purpose. This bill is sponsored by Latino Coalition for a Healthy California. According to the author:

[CHWs] provide an essential service by helping Spanish speakers, immigrants, indigenous people, and many others navigate the system by providing guidance through the medical process. While these services have been a covered Medi-Cal benefit for a few years, there has been very little uptake, and we're not currently sure why. [This bill] will give us answers by requiring DHCS…to report to the legislature on current outreach efforts and if there is need for further legislative action.

1. Background. DHCS added CHW services as a Medi-Cal benefit starting July 1, 2022, and has also leveraged CHWs/Promotores/Community Health Representatives (CHW/P/Rs) in specific roles under the Medi-Cal transformation project called California Advancing and Innovating Medi-Cal (CalAIM). Under Medi-Cal, supervising providers may bill for CHW services, including health education, navigation, screening and assessment to determine need for services, and individual support and advocacy across a wide range of health conditions, including behavioral health. The CHW benefit defines CHWs to include promotores, CHRs, violence prevention specialists, and individuals with similar titles who perform this work and meet a set of core competencies.
   
   The 2023 Budget Act and the 2024-25 Governor’s Budget each assumed total annual Medi-Cal expenditures of $91.9 million for the CHW benefit ($82.7 million in managed care and $9.2 million in fee-for-service). However, as of January 25, 2024, less than $1 million had been billed specifically for the CHW benefit. Budget estimates for new benefits, particularly when provided by non-traditional providers, are often uncertain and a ramp-up period is expected. Although thousands of Medi-Cal members appear to 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.
2. Prior Legislation.
   
   AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022, codified CHW services as a covered Medi-Cal benefit.
   
   SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, appropriated $281.4 million over three years to support a new program administered by the Department of Health Care Access and Information (HCAI) to recruit, train, and certify 25,000 new CHW/P/Rs by 2025. However, before resources were deployed to train CHW/P/Rs, $250 million was cut from HCAI CHW initiatives as a budget-balancing reduction in the 2024-25 fiscal year.

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

Date of Hearing: March 25, 2025

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 403

Author:(Ortega) – As Amended Ver:March 17, 2025

SUBJECT: Medi-Cal: community health worker services.

SUMMARY: Requires Department of Health Care Services (DHCS) to report annually on several aspects of the Medi-Cal Community Health Worker (CHW) benefit, including assessing outreach and education efforts by managed care plans, CHW spending and utilization, referrals by provider type, and demographic disaggregation of CHWs and Medi-Cal members receiving CHW services.

EXISTING LAW:

1. Specifies CHW services as a covered benefit under Medi-Cal. [Welfare & Institutions Code (WIC) § 14132.36]
2. 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 a CHW is a frontline health worker either trusted by, or who has a close understanding of, the community served, and requires a CHW’s lived experience to align with and provide a connection to the community being served. [WIC § 18998]
3. States that CHWs include Promotores, Promotores de Salud, community health representatives, navigators, and other nonlicensed health workers, including violence prevention professionals. [ibid.]
4. Requires Department of Health Care Access and Information (HCAI) to develop statewide requirements for CHW certificate programs in consultation with stakeholders, including, but not limited to, the DHCS, the California Department of Public Health, CHWs, Promotores and Promotores de Salud, or representative organizations. [ibid.]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the health care system is already complicated for people whose first language is English; for individuals with language barriers, navigating our complex system can be an insurmountable challenge. The author notes CHWs and promotores provide an essential service by helping Spanish speakers, immigrants, indigenous people, and many others navigate the system by providing guidance through the process of seeking medical care. The author expresses concern that while these services have been a covered Medi-Cal benefit for a few years, there has been very little uptake, and we don’t know why. The author argues this bill will provide answers by requiring DHCS to report to the Legislature on utilization, current outreach efforts, and the status of CHW participation in Medi-Cal. The author concludes this will allow the Legislature to monitor uptake of the CHW benefit and decide if there is need for further legislative action.
2. BACKGROUND.
   1. CHWs. According to the National Association of Community Health Workers, “CHW” is used as an umbrella term to describe community health representatives, promotores de salud or promotoras, outreach workers, and many other different work titles. CHWs share life experience with the people they serve and have firsthand knowledge of the causes and impacts of health inequity. In the United States, the majority of CHWs serve communities that have experienced structural oppression and who may be marginalized by traditional health care systems, including Black, Latinx, American Indian/Alaska Native, and Asian/Pacific Islander communities, as well as rural and low-income communities.

According to the American Public Health Association (APHA), CHWs are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also 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. APHA’s definition is commonly cited by other organizations. California’s Welfare and Institutions Code Section 18998 contains a similar definition, and emphasizes that a CHW’s lived experience aligns with and provides a connection to the community being served. Although CHW is commonly used as an umbrella term, promotores and Community Health Representatives (CHRs) have distinct histories and footprints in California. Promotores de salud, or promotores, are lay health workers who most often provide culturally congruent services informed by their lived experiences to Spanish-speaking communities, while CHRs serve in tribal communities.

• 1. Efforts to Promote and Sustain the CHW Workforce and CHW Services.
     1. Medi-Cal Benefit. DHCS added CHW services as a Medi-Cal benefit starting in July 1, 2022, and has also leveraged CHWs/Promotores/Community Health Representatives (CHW/P/Rs) in specific roles under the Medi-Cal transformation project called California Advancing and Innovating Medi-Cal (CalAIM). Under Medi-Cal, supervising providers can bill for the services CHWs provide, including health education, navigation, screening and assessment to determine need for services, and individual support and advocacy across a wide range of health conditions, including behavioral health. The CHW benefit defines CHWs as inclusive of promotores, CHRs, violence prevention specialists, and individuals with similar titles who perform this work and meet a set of core competencies.
     2. Halting CHW Workforce Efforts. The 2022 Budget Act included $281.4 million over three years to support a new program administered by HCAI to recruit, train, and certify 25,000 new CHW/P/Rs by 2025, including those with specialized training to work with specific populations or on specific issues. 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/P/R certificate programs in consultation with stakeholders. However, before resources were deployed to train CHW/P/Rs, $250 million was cut from HCAI CHW initiatives as a budget-balancing reduction in the 2024-25 fiscal year. According to HCAI, this left insufficient funds to implement any ongoing functions, including individual certificate or program accreditation functions. HCAI maintains $12M in one-time funds for the CHW/P/R workforce and has developed a proposed funding framework for these funds, which includes technical assistance and direct funding for community-based organizations (CBOs) for Medi-Cal billing infrastructure development, as well as other items. In addition, in 2024, HCAI invested $10 million via a one-time legislative augmentation in small and medium-sized CBOs who work with promotores and CHWs to increase their capacity to serve their communities.
     3. Private-Sector Activity and Innovation. The California Health Care Foundation’s “Expanding the Community Health Worker / Promotor / Representative Workforce” project has continued to support the expansion of CHW workforce and services through resources and convenings. Private entities that train CHWs, such as El Sol Neighborhood Education Center, Vision y Compromiso, and community colleges have continued these activities. In addition, “Community Care Hubs” have emerged as an innovative strategy to create networks of community-based organizations and other nontraditional Medi-Cal providers like peer support specialists, doulas, and CHWs. These hubs offer value to nontraditional providers by assisting with administrative tasks such as managed care contracting, data management, and referrals, and they simplify contracting for managed care plans by centralizing these processes, allowing plans to more easily expand their networks of nontraditional providers.
  2. Challenges with Expanding CHW Services and Monitoring Utilization. On March 12, 2024, the Assembly Health Committee and Budget Subcommittee #1 on Health held a hearing examining state efforts on CHWs, titled, “Bright Spots and Remaining Barriers to Realizing the Potential of Community Health Workers, Promotoras, and Representatives to Improve Health in California.”

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 assumed 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, actual utilization has fallen far short of these initial estimates. As of January 25, 2024, data indicated less than $1 million had been billed specifically for the CHW benefit. 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.

Given costs for CHW services are assumed to be subsumed within broader Medi-Cal “capitation” (per member, per month) rates paid to Medi-Cal managed care plans that cover a range of services, DHCS no longer separately reports data for CHW utilization and spending in Medi-Cal budget estimates.

1. SUPPORT. Numerous community-based organizations; health, racial equity, and consumer advocacy organizations; and providers of CHW and other health services support this bill. Supporters note the lack of data on CHW utilization has made it extremely difficult to identify and address the many implementation barriers and to evaluate the availability and effectiveness of these services in addressing disparities in health outcomes. Supporters argue the legislation will provide transparency on the current number of CHW/P/Rs providing services, as well as those enrollees receiving these services, so we can actually meet the goals of reducing health disparities for communities across California.
2. RELATED LEGISLATION.
   1. AB 29 (Arambula), pending in this committee, would allow doulas, as well as community-based organizations and local health jurisdictions that provide health services through CHWs, to provide Adverse Childhood Experiences trauma screenings (ACEs screening) and make them eligible for Medi-Cal reimbursement for the screening.
   2. AB 73 (Jackson), pending in this committee, would require HCAI to develop, as a component of an existing CHW certificate program, criteria for a specialty certificate program and specialized training requirements for a Black Mental Health Navigator Certification, and report related program data.
   3. AB 96 (Jackson), pending in this committee, would deem a certified peer support specialist to have satisfied all education and training requirements developed by DHCS for certification as a CHW.
3. PREVIOUS LEGISLATION.
   1. AB 2110 (Arambula) of 2024, was similar to AB 29 and was held on suspense in the Assembly Appropriations Committee.
   2. AB 2250 (Weber) of 2024, would have required a health plan, health insurer, and Medi-Cal to provide coverage for, and provider reimbursement of, social determinants of health (SDOH) screenings; required a health plan or insurer 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; and provided for reimbursement of SDOH screenings at the Medi-Cal fee-for-service rate for federally qualified health centers and rural health clinics. AB 2250 was vetoed by Governor Newsom, who expressed support for the overall goal of this proposal, but stated that it is duplicative of existing efforts.
   3. AB 85 (Weber) of 2023 was similar to AB 2250 (Weber), above, and required HCAI to convene a working group. AB 85 was also vetoed by Governor Newsom, who expressed support for the overall goal of the proposal, but stated that it is duplicative of existing efforts.
   4. AB 2697 (Aguiar-Curry), Chapter 488, Statutes of 2022, codifies CHW services as a covered Medi-Cal benefit.
   5. SB 184 (Committee on Budget and Fiscal Review), Chapter 47, Statutes of 2022, codifies the HCAI CHW workforce initiative.

REGISTERED SUPPORT / OPPOSITION:

Support

California Pan - Ethnic Health Network (co-sponsor)

Latino Coalition for a Healthy California (co-sponsor)

The Children's Partnership (co-sponsor)
Vision y Compromiso (co-sponsor)

AAPI Equity Alliance
Alianza for Opportunity
Alzheimer's Association
APLA Health
Asian Americans Advancing Justice-Southern California
Asian Americans for Community Involvement
Asian Pacific Partners for Empowerment, Advocacy and Leadership
Asian Resources, Inc.
Asociacion De Migrantes Guatemaltecos, LA
Black Women for Wellness Action Project
California Alliance of Child and Family Services
California Immigrant Policy Center
California LGBTQ Health and Human Services Network
California Rural Legal Assistance Foundation, Inc.
Cancer Kinship
Casa Del Diabetico Gualan
Ceres Community Project
Drug Policy Alliance
Esperanza Community Housing Corporation
Farm2people
Food Empowerment Project
Full Circle Health Network
Health Access California

Los Amigos De LA Comunidad
Mixteco/indígena Community Organizing Project (MICOP)
National Health Law Program
Nourish California
Oasis Legal Services
Regional Asthma Management & Prevention
San Ysidro Health
South Asian Network
Southeast Asia Resource Action Center
The Children's Partnership
UCLA Latino Policy and Politics Institute
Union De Guatemaltecos Emigrantes
Western Center on Law & Poverty

Opposition

None on file.

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