Frequently Asked Operational Questions

No. ACE screenings are not mandatory. Medi-Cal providers are encouraged to screen Medi-Cal pediatric and adult patients. Medi-Cal providers can receive payment for providing qualified ACE screenings since they will be a Medi-Cal-covered benefit beginning on January 1, 2020.

Implementation of these payments for screenings provided to beneficiaries enrolled in an MCP is subject to obtaining the necessary federal approvals.

No. It is not mandatory. Medi-Cal beneficiaries do not have to complete an ACE screening.

Yes. Eligible Medi-Cal providers who screen Medi-Cal patients for ACEs can receive payment as of January 1, 2020. Beginning on July 1, 2020, Medi-Cal providers must have taken a certified Core Training and self-attested to completing the training to continue to receive Medi-Cal payment for ACE screenings. There is currently one Core Training available, Becoming ACEs Aware in California.

Yes. MCPs will pay network providers for completing qualifying ACE screenings on Medi-Cal beneficiaries enrolled in a MCP.

For children, the screening tool required for use is the Pediatric ACEs and Related Life-events Screener (PEARLS) tool. There are versions of the tool based upon age: PEARLS for children ages 0-11, to be completed by a caregiver; PEARLS for teenagers 12-19, to be completed by a caregiver; and PEARLS for teenagers 12-19, self-reported. All versions of PEARLS are available as identified and de-identified screeners. The ACE score refers only to Part 1 of PEARLS (Part 2 asks about social determinants of health and is not required).

In total, there are eight versions of the PEARLS tool:

• PEARLS for children ages 0-11, to be completed by a caregiver with identified responses
• PEARLS for children ages 0-11, to be completed by a caregiver with de-identified responses
• PEARLS for children ages 0-11, with de-identified responses in Part 1 and identified responses in Part 2
• PEARLS for adolescents 12-19, to be completed by a caregiver with identified responses
• PEARLS for adolescents 12-19, to be completed by a caregiver with de-identified responses
• PEARLS for adolescents 12-19, self-reported with identified responses
• PEARLS for adolescents 12-19, self-reported with de-identified responses
• PEARLS for adolescents 12-19, self-reported with de-identified responses in Part 1 and identified responses in Part 2

Eligible providers will be paid for the screening if any of the versions are used. The ACEs screening portion (Part 1) of the PEARLS tool is also valid for use to conduct ACEs screening among adults age 20 and older. Access the screening tools.

For adults, the screening tool required for use is the ACE Assessment Tool adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention. Access the Identified and de-identified versions of the screening tools. If an alternative version of the ACE questionnaire for individuals age 20 and older is used, it must contain questions on the ten original categories of ACEs (and be available in an identified and de-identified response format) to qualify for payment.

No. Eligible Medi-Cal providers who conduct qualifying ACE screenings will be paid up to $29 in the fee-for-service (FFS) delivery system and no less than $29 in the medical managed care delivery systems.

Yes. The screening tools will be available on the DHCS Trauma Screenings and Trauma-Informed Care Provider Trainings webpage. Screening tools are also currently available on the ACEs Aware website.

To bill Medi-Cal, providers should use the Healthcare Common Procedure Coding System (HCPCS) billing codes based on the results of the screening. Code G9919 is used for screens that have a score of 4 or greater (high risk) and code G9920 is used for screens that have a score of 0 to 3 (lower risk). Billing requires that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the beneficiary and/or family, and any clinically appropriate actions were documented. This documentation should remain in the beneficiary’s medical record and be available upon request.

The ACE Screening Clinical Algorithm (ADA version) helps a provider assess whether a patient is at low, intermediate or high risk of a toxic stress physiology, and how to incorporate ACE screening results into clinical care and follow-up plans. The algorithm is based on a combination of both the ACE score and presence or absence of ACE-Associated Health Conditions.

Clinical response to identification of ACEs and increased risk of toxic stress should include:

1. Applying principles of trauma-informed care including establishing trust, safety and collaborative decision-making.
2. Identification and treatment of ACE-Associated Health Conditions by supplementing usual care with patient education on toxic stress and strategies to regulate the stress response including:
   1. Supportive relationships;
   2. Mental health treatment (if indicated);
   3. Regular exercise;
   4. Good sleep hygiene and high-quality sleep;
   5. Healthy nutrition; and
   6. Mindfulness practices.
3. Validation of existing strengths and protective factors.
4. Referral to patient resources including educational materials, community resources, social work, and/or mental health care as necessary.
5. Follow-up as necessary.

Clinical team members can take a free, two-hour training to learn about ACEs, screening tools, and trauma-informed care. Register for the certified Core Training at https://training.acesaware.org/. Additional trainings will be offered in 2020. Clinical team members may receive Continuing Medical Education (CME) credits and Maintenance of Certification (MOC) credits upon completion. More information on credits can be found on the training website.

The training educates Medi-Cal providers about the importance of incorporating ACE screenings into their clinical practices, how to conduct ACE screenings, how to use clinical protocols to determine treatment plans, and best practices in providing trauma-informed care. Information for all providers interested in ACEs and trauma-informed care, as well as patients who have questions, is available at www.ACEsAware.org.

The training is available to any clinician team or staff members, but it is particularly geared towards primary care clinicians. Clinicians who will implement ACE screening in their practice should take the training and attest to completing it to qualify for Medi-Cal payment. Other clinicians and staff may also benefit from taking the training, but are not required to attest.

For more information on eligibility to receive Medi-Cal payment for ACE screenings, view eligible provider types.

Yes. You can earn 2.0 Continuing Medical Education (CME) credits and 2.0 Maintenance of Certification (MOC) credits by taking the “Becoming ACEs Aware in California” training. You can earn additional education credit by completing additional cases.

• The Postgraduate Institute of Medicine accredited the “Becoming ACEs Aware in California” training for:
  • 2.00 American Medical Association (AMA) Physician’s Recognition Award (PRA) Category 1 Credit™
  • 2.00 American Academy of Family Physicians (AAFP) Prescribed credits
  • 2.00 American Nurses Credentialing Center (ANCC) contact hours
  • 2.00 American Academy of PAs (AAPA) Category I CME credits
  • 2.00 American Psychological Association (APA) Continuing Education (CE) credits
  • 2.00 Association of Social Work Boards (ASWB) CE credits
  • 2.00 NAADAC (the Association for Addiction Professionals) credits
  • 2.00 American Board of Internal Medicine’s (ABIM) points in the MOC II program
  • 2.00 American Board of Pediatrics’ (ABP) points in the MOC program

Learners may also take the course for attendance only. More information about credit types is available on the “Becoming ACEs Aware in California” training page.

The “Becoming ACEs Aware in California” training takes approximately two hours to complete.

Yes. In order to receive the payment, eligible providers must complete the Becoming ACEs Aware in California training or an ACEs Aware-certified Core Training. ACEs Aware is partnering with organizations across California to create additional training opportunities for providers interested in learning more about ACE screening and trauma-informed care.

There is not a “train the trainer” component for the ACEs Aware initiative at this time. When available, we will post all training opportunities on the ACEs Aware website.

The ACEs Aware initiative is providing grants and additional opportunities to support community and in-person ACEs Aware trainings. When available, we will post all training opportunities on the ACEs Aware website.

Qualifying ACE screenings are eligible for payment in any clinical setting in which billing occurs through Medi-Cal fee-for-service or to a network provider of a managed care plan. For services provided on or after January 1, 2020, the following enrolled Medi-Cal provider types are eligible to receive payment:

• Certified Nurse Midwife
• Certified Nurse Practitioner
• Group Certified Nurse Practitioners
• Early and Periodic Screening, Diagnostic, and Treatment Services Providers
• Licensed Clinical Social Worker – Individual, Group
• Licensed Nurse Midwife
• Licensed Professional Clinical Counselor – Individual, Group
• Marriage and Family Therapist – Individual, Group
• Physician
• Physician Group
• Psychologist
• County Hospital – Outpatient
• County Clinics not associated with a Hospital
• Indian Health Services (IHS)/Memorandum of Agreement
• Otherwise Undesignated Clinic
• Outpatient Heroin Detox Center
• Rehabilitation Clinic
• Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC)
• In-state and border providers

To receive payment through Medi-Cal managed care, the provider also needs to be a network provider of a Medi-Cal managed care health plan billing for services provided to a member of that health plan.

Yes, providers may screen a patient for ACEs via telehealth if the provider believes that the ACE screening can be administered in a clinically appropriate manner via telehealth, per new DHCS guidance in response to COVID-19. Providers must continue to comply with all other billing procedures, Medi-Cal guidelines, and confidentiality laws.

Under the existing ACE screening policy, providers must document all of the following: the tool that was used, that the completed screen was reviewed, the results of the screen, the interpretation of results, what was discussed with the member and/or family, and any appropriate actions taken. This documentation must remain in the beneficiary’s medical record and be available upon request.

See more information about telehealth and virtual/telephonic communications under the new COVID-19-related guidance.

Billing and coding are based upon the beneficiary’s total ACE score. The ACE score refers to the total reported exposure to the ten ACE categories indicated in the adult ACE assessment tool or the first box of the PEARLS tool. ACE scores range from 0 to 10.

To bill Medi-Cal, providers should use the Healthcare Common Procedure Coding System (HCPCS) billing codes based upon the results of the screening.

• HCPCS code G9919 is used for screens that have a score of 4 or greater (high risk)
• HCPCS code G9920 is used for screens that have a score of 0 to 3 (lower risk)

Billing requires that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the beneficiary and/or family, and any clinically appropriate actions were documented. This documentation should remain in the beneficiary’s medical record and be available upon request.

DHCS will not, and MCPs are not required to, provide the payment for ACE screening for beneficiaries age 65 and older. Providers will not be reimbursed for providing an ACE screen to dually eligible beneficiaries with Medi-Cal and Medicare Part B. Providers can screen beneficiaries age 65 and older and those dually eligible for Medicare and Medi-Cal but will not receive any payment from Medi-Cal.

ACE screenings are eligible for payment in any clinical setting in which billing occurs through Medi-Cal fee-for-service or to a network provider of a medical managed care plan. In most cases, ACE screenings are most appropriately delivered in an outpatient primary care setting.

School-based health centers (SBHCs) are a vital place for vulnerable children to connect with supportive adults and peers outside their families. The ability for eligible providers at SBHCs to bill Medi-Cal for qualified ACE screenings depends on the way the SBHC administers and bills for services.

SBHCs vary widely in their billing arrangements across the State of California – some bill as Local Education Agencies (LEAs) and others are run by Federally Qualified Health Centers (FQHCs), county health departments, or other community health centers. The ACEs Aware website provides a list of provider types eligible for Medi-Cal payment for screening for ACEs, which includes FQHCs, county hospitals (outpatient), and county clinics not associated with a hospital. In general, eligible providers at SBHCs operated by an FQHC may bill for ACE screenings, however LEAs are not eligible for payment. Licensed Medi-Cal providers at SBHCs should check with their parent organization before billing for ACE screenings. More information regarding FQHC eligibility can be found on the Policy Guidance page.

Yes, and we encourage you to do so! The Pediatric ACEs and Related Life Events Screener (PEARLS) and ACE Questionnaire for Adults are in the public domain and may be reproduced and redistributed if they are for non-commercial use only and the materials acknowledge the original source of the ACEs Aware website and original authors.

The Pediatric ACEs Screening and Related Life-events Screener (PEARLS) was developed by the Bay Area Research Consortium on Toxic Stress and Health (BARC), a partnership between the Center for Youth Wellness, the University of California, San Francisco (UCSF), and UCSF Benioff Children’s Hospital Oakland. The ACE Questionnaire for Adults was adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). A version of the tool has been compiled and posted by the Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory Subcommittee.

Entities may not charge their users for accessing information provided by the ACEs Aware initiative – including screening tools. The tools may only be reproduced or disseminated in accordance with the Terms of Use, available here: https://www.acesaware.org/terms-of-use/.

If the emergency physician is an eligible Medi-Cal provider, and by July 1, 2020, has self-attested to completing the certified Core Training, the provider would qualify for Medi-Cal reimbursement for screening their Medi-Cal patients. Billing requires that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted, results were discussed with the beneficiary and/or family, any clinically appropriate actions were documented , and this documentation remains in the patient’s medical record. However, this screening is intended for primary care providers and/or providers with ongoing patient contact. While it is recognized that on occasion emergency physicians may provide primary care to patients, DHCS anticipates that the emergency room will not usually be an appropriate setting for this particular screening and any follow-up care.

For screenings provided to beneficiaries enrolled in a Medi-Cal MCP, the provider must be a network provider of the MCP in order to qualify for the payment for each screening.

If the supervising physician is an eligible Medi-Cal provider, has taken the training, and assumes responsibility for ensuring that the completed screen was reviewed, the appropriate tool was used, results were documented and interpreted correctly, results were discussed with the beneficiary and/or family, any clinically appropriate actions were documented, and this documentation remains in the medical record, then they can bill on behalf of a physician assistant or nurse practitioner who provides the screening and associated follow up to Medi-Cal patients.

DHCS encourages all providers conducting ACE screenings, even non-billing providers, to complete the certified Core Training.

An FQHC may receive payment for both the parent and child ACE screening that occurs during a well-child visit. Because the screenings occur during one encounter, an FQHC should submit ACE screening claims as follows:

· Claim 1 – ACE screening for child (appropriate encounter codes)

· Claim 2 – ACE screening for parent (no encounter codes)

The clinician must be an eligible Medi-Cal provider that has self-attested to completing a certified ACEs Aware Core Training, and all documentation requirements must be followed for the parent and the child.

There is no set timeline for ACE screening implementation. The timeline depends on a variety of factors such as staff availability, leadership buy-in, previous experience, existing partners, size of practice, and other factors. Consider past efforts of integrating new practices at your clinic to estimate your timeline.

Not necessarily. Becoming more trauma-informed as an organization is a journey that consists of many steps over time. You can develop an ACE screening implementation plan while working to integrate trauma-informed care. In fact, preparing for and implementing ACE screening can be an effective early step in helping to move a practice toward a more trauma-informed approach to care. 

ACE screening may involve many aspects of your practice, so consider a broad list of potential stakeholders, including those who may champion ACE screening, advance decision-making in the organization, and support the implementation process more directly. To determine which decision-makers to engage, consider who is necessary to get on board to implement screening (e.g., who is on the board of directors), who makes the clinical decisions, who makes financial decisions, and who will evaluate progress. In addition, consider engaging clinical, administrative, and community champions to help build support, influence decision-makers, and inform the implementation team’s planning.

Strategies that may help include providing education and resources to help leadership and other colleagues build their own knowledge; creating space to test and learn as you go (i.e., piloting and adapting screening and response); and linking to other experts in your community and beyond to help you and others continue with ongoing learning.

The stages and steps in the ACE Screening Implementation How-To Guide will take you through the process of preparing your practice for ACE screening and responding to the results. The guide’s recommended staged approach to piloting and scaling up will enable you to start small and build on what you learn, working incrementally to augment your resources and referral partners, and engage others at your practice.

The How-To Guide helps practices identify multiple response strategies, such as patient education, anticipatory guidance, and medical follow-up for ACE-Associated Health Conditions (AAHCs). It also recommends how to expand the network of referral partners to include those who are specialists focused on AAHCs, and who can help meet unmet basic needs, provide social support, and support evidence-based strategies to treat toxic stress (e.g., high-quality, sufficient sleep; balanced nutrition; regular physical activity; mindfulness and meditation; experiencing nature; and mental health care, when indicated).

It may. Teams at smaller practices may be made up of a few team members who are responsible for multiple roles at the practice and may also have multiple roles on the implementation team. At larger multi-site or multi-department practices, the team may need to be larger to represent each department and specialized roles, such as quality improvement (QI), and each member might be able to focus on a single team role.

Once you are familiar with the rationale for ACE screening, as well as with ACEs and toxic stress science, you can develop a compelling case for your organization to implement a screening initiative ​by explaining how screening can generate revenue for your clinic through billing and can improve the health outcomes of patients. Other strategies reported by clinics that have successfully implemented ACE screening include offering administrative time to clinician champions, shifting staff responsibilities to free up time for implementation activities, or finding philanthropic and operational funding to pay for staff time. ACE screening is no different than successfully accomplishing other important strategic initiatives in health care.

Every implementation team will be different, depending on your practice structure, type, and size. While there are many different roles to consider including on your team, it is important that at least one member of the team has strong expertise in the science of ACEs and toxic stress.

No matter how often your team decides to meet, it is important to schedule meetings on a regular basis. The team should meet often enough so that team members have the information and support they need to keep moving forward with their responsibilities.

ACE screening has been successfully integrated into a wide range and size of clinical settings and practice specialities, including pediatric primary care, adult primary care, family medicine, and women’s health, including prenatal care. However, practices encountered questions and concerns from their colleagues as they got started. Commonly referenced questions by leadership include cost, impact on clinical and staff capacity, and availability of support resources. Some areas that clinicians and staff have been concerned about include having insufficient time during appointments to screen and effectively respond, a comfort level talking about ACEs, perceived or actual lack of support services for response, and fear that patients will reject screening. There have also been concerns about patient health literacy about ACEs and screening fatigue. For strategies to help address these concerns, read How to Make the Case for ACE Screening to Practice Leadership.

Providers can self-attest to their one-time completion of the state-certified trauma-informed care training on the Medi-Cal Trauma Screening Training Attestation page. DHCS will maintain a list of providers who have self-attested to their completion of the training that can also be accessed by MCPs.

Beginning July 1, 2020, Medi-Cal providers must attest to completing certified ACEs training on the DHCS website to continue receiving payment.

Effective January 1, 2020, qualified Medi-Cal providers began receiving payment for screening children and adults for ACEs using an approved screening tool. Beginning July 1, 2020, eligible Medi-Cal providers must self-attest to completing certified ACE training to continue receiving payments for screenings delivered after that date.

Yes, and we encourage providers to do so! Providers may complete a certified ACE training and self-attest to completing a training after July 1^st, but they will only be reimbursed for conducting qualified screenings after they have self-attested.

Providers should use their personal National Provider Identifier (NPI) and Taxpayer Identification Number (TIN), if available, on the ACEs Provider Attestation Form. If a provider does not have a personal TIN, they should use their business’ TIN. NPI and TIN will only be used to verify providers’ identities and will not be shared publicly.

If a provider makes an error in filling out the ACEs Provider Attestation Form, they should re-complete and re-submit the form. The most recent attestation form submitted by a provider will be used by the Department of Health Care Services.

No, a confirmation email is not sent after a provider submits the ACEs Provider Attestation Form.

The ACEs Aware Initiative is developing a directory of Medi-Cal providers who have completed a certified ACEs Aware training to help Medi-Cal patients find “ACEs Aware” providers. If you choose to enroll in the ACEs Aware provider directory, only the information under the “ACEs Aware Provider Directory” heading on the ACEs Provider Training Attestation form will be shared publicly.

DHCS maintains a list of providers who have self-attested to completing an ACEs Aware certified Core Training. Entities that bill Medi-Cal may request provider attestation data for program implementation purposes such as confirming that your providers have submitted an attestation form. The Department of Health Care Services will release First Name, Last Name, and National Provider Identifier of providers who have completed the attestation form to approved requestors. Please complete this form to request ACEs provider attestation data.

DHCS updates the ACEs Provider Training Attestation data file once per month on the first of the month. Currently, only Medi-Cal managed care plans have access to the list of providers who have self-attested to their completion of a core certified ACEs Aware training.

When Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Cost-Based Reimbursement Clinic (CBRC), Indian Health Services – Memorandum of Agreement (IHS-MOA) 638 Clinics and other provider groups submit a claim for a qualified ACE screening, clinics are responsible for ensuring that the rendering provider has completed and attested to completing a certified ACEs training, per the ACEs Screening Program Integrity Newsflash.

As stated in the All Plan Letter 19-018: Proposition 56 Directed Payments for Adverse Childhood Experiences Screening Services, Managed Care Plans (MCPs), or their delegated entities, are responsible for ensuring their delegates comply with all applicable state and federal laws and regulations, contract requirements and other DHCS guidance. MCPs will have access to the list of providers that have self-attested to completing a certified ACEs training.

DHCS will include information about ACEs Aware in its existing stakeholder update communications. ACEs Aware will also provide email updates; email info@acesaware.org to sign up.

FQHCs are eligible to receive the $29 payment for ACE screenings, in addition to their existing Prospective Payment System payment. FQHCs should bill for the patient’s visit and bill separately for the qualified ACE screening.

FQHCs are eligible to receive the $29 payment for ACE screenings, in addition to their existing Prospective Payment System (PPS) payment. Mental health services are not always required for treatment of toxic stress (please refer to the Clinical Assessment & Treatment Planning page for more information). In cases where a patient requires mental health services, if the patient receives mental health services on the same day as the physical health visit, the FQHC will receive one PPS rate. If a patient receives mental health services during another visit on a different day as the physical health visit, the FQHC will receive the PPS rate for each visit.