Application Instructions - CalHealthCares Proposition 56 Medi-Cal Physicians and Dentists Loan Repayment Program - Physicians for a Healthy California
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CalHealthCares
Proposition 56 Medi-Cal Physicians
and Dentists Loan Repayment
Program
Application Instructions
Application Cycle:
January 18 – February 12, 2021
(11:59PM PST)
Page 1 of 83 Rev. 01/18/2021
DHCS has contracted with (916) 551-2579
Physicians for a Healthy California CalHealthCares.org
to administer CalHealthCares. CalHealthCares@phcdocs.org
APPLICATION INSTRUCTIONS
Table of Contents
INTRODUCTION………………………………………………………………………………………………………………………………………..3
Loan Repayment Program………………………………………………………………………………………………………………………………………...….4
Loan Repayment Program Taxable Income Status………………..…………………,,…………………………………..………………….5
Practice Support Grant………………………………………………………………………………………………………………………………………………......6
Practice Support Grant Taxable Income Status………………………………………………………………………………………………......7
PROGRAM REQUIREMENTS…………………………………………………………………………………………………………………….7
Patient Caseload…………………………………………………………………………………………………………………………………………………………….….8
ELECTRONIC APPLICATION…………………………………………………………………………………………………………………..10
Before You Apply…………………….………………………………………………………………………………………………………………………………………..10
Using and Navigating the E-app…………………….……………………………………………………………………………………………………......10
Step 1: Eligibility…………………………………………………………………………………………………………………………………………………………………14
Step 2: Communications…………………………………………………………………………………………………………………………………..……….…20
Step 3: Applicant Information…………………………………………………………………………………………………………………………………....22
Step 4: Facility.Information………………………………………………………………………………………………………………………………………….24
Step 5: Educational History………………………………………………………………………………………………………………………………………….29
Step 6: Funds Requested……………………………………………………………………………………………………………………………………………..37
Step 7: Patient Caseload……………………………………………………………………………………………………………………………………………….42
Step 8: Personal Statement………………………………………………………………………………………………………………………………………..47
Step 8: Valid Business Plan (Practice Support Grant Only) ……………………………………………………………………………….48
Step 9: Attestations………………………………………………………………………………………………………………………………………….……………..46
Step 10: Program Requirements………………………………………………………………………………………………………………………………49
Step 11: Application Review………………………………………………………………………………………………………………………………………...49
Application Submission……..………………………………………………………………………………………………………………………………….……..52
GETTING QUESTIONS ANSWERED……………………………………………………………………………………………………….53
REVIEW AND SELECTION PROCESS……………………………………………………………………………………………..……..54
HELPFUL TIPS……………………………………..……………………………………………………………………………………………..…..54
APPENDICES…………………………………………………………………………………………………………………………………………..56
Appendix A: Complete List of Physician Specialties…………………………………………………………………………………………56
Appendix B: EVF Sample…………………………………..………………………………………………………………………………………………………...61
Appendix C: Visual for Submitting EVF’s……………………………..………………………………………………………………………………..64
Appendix D: Total Payoff Balance Statement……………………………………………………….…………………………………………….67
Appendix E: How to Calculate Patient Caseload………………………………………………………………………………………………..72
Appendix F: Scoring Matrix by Track………………………………………………………………………………………..……………………………..75
Appendix G: Business Plan Guidelines…………………………………………………………………………………………………..………………81
Page 2 of 83 Rev. 01/18/2021
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APPLICATION INSTRUCTIONS
Note: These headings will be in green font throughout this manual for ease of navigation.
INTRODUCTION
In 2018, SB 849 established the Proposition 56 Medi-Cal Physicians and Dentists Loan Repayment Act
Program, named the CalHealthCares program, and appropriated $220 million for the loan assistance
program for recently graduated physicians and dentists. An additional $120 million was added to the
program in Governor Newsom’s revised 2019-20 budget. A total of $340 million has been allocated to the
CalHealthCares program from Proposition 56 revenue. The Department of Health Care Services (DHCS)
has contracted with Physicians for a Healthy California (PHC) to administer the CalHealthCares program.
Approximately $69.3 million was available annually for funding for the first two cycles, FY 2018-19 and FY
2019-20. The following tables illustrate the funding available for FY 2018-19 through FY 2022-23 cycles. This
will result in awards for approximately 917 physicians (See Table 1 below) and 158 dentists (See Table 2 below)
over the course of the program – assuming all awards are funded at $300,000.00 per awardee. Per
Proposition 56, up to 5% of all available funds may be directed for administrative expenses associated
with administering the program.
Table 1: Approximate Funding and Awarding Available for Physicians
Years Year 1 Year 2 Year 3 Year 4 Year 5 Totals
Funding $58.6 $58.6 $56.1 $56.1 $46.1 $275.5
million million million million million million
Number of
Physicians 195 195 187 187 153 917
Note: These numbers are approximate assuming all awards are $300,000.00 per awardee.
Table 2: Approximate Funding and Awarding Available for Dentists
Years Year 1 Year 2 Year 3 Year 4 Year 5 Totals
Funding $10.7 $10.7 $9.7 $8.2 $8.2 $47.5
million million million million million million
Number of
Dentists 36 36 32 27 27 158
Note: These numbers are approximate assuming all awards are $300,000.00 per awardee.
Per Senate Bill 849, CalHealthCares was created to provide loan assistance payments to qualifying
recently graduated physicians and dentists who serve beneficiaries of Medi-Cal and Medi-Cal Dental,
California’s Medicaid program. Recently graduated physicians are defined as having graduated from
either a residency or fellowship program within the last five years (between January 1, 2016 and June 30,
2021). Qualifying physicians may apply to the Loan Repayment Program. Recently graduated dentists for
the Loan Repayment Program are defined as having graduated from dental school or a dental residency
program within the last five years (between January 1, 2016 and June 30, 2021). Recently graduated
dentists for the Practice Support Grant are defined as having graduated from dental school within the
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APPLICATION INSTRUCTIONS
last 15 years (on or after January 1, 2006). Qualifying dentists may apply for the Loan Repayment Program
or the Practice Support Grant – dentists may not apply for both. All medical and dental specialties are
eligible to apply.
Loan Repayment Program: This section contains information for dentists and dental
students/residents, physicians and physician residents/fellows applying to the CalHealthCares Loan
Repayment Program.
Eligible physicians and dentists may receive loan repayment of up to $300,000.00 in exchange for a five-
year service obligation. All specialties are welcome to apply. Physicians (Medical Doctor and Doctor of
Osteopathic Medicine) practicing medicine in primary, specialty, and sub-specialty care are eligible to
apply. Dentists (Doctor of Dental Surgery or Doctor of Medicine in Dentistry) practicing general and/or
specialty dentistry are eligible to apply.
Below is the List of Loan Repayment Applicant Requirements:
+ Have an unrestricted license and be in good standing with the Medical Board of California,
Osteopathic Medical Board of California or Dental Board of California
+ Be an active enrolled Medi-Cal provider without existing suspensions, disbarments or revocations
or have applied to DHCS to become an active enrolled Medi-Cal provider
+ Have graduated from a physician residency program and/or completed a physician fellowship
program or have graduated from a dental school, dental residency program or dental fellowship
program between January 1, 2016 and June 30, 2021 (graduates of national and/or international
schools of medicine are eligible to apply)
+ Have existing educational loan debt incurred while pursuing a medical degree, residency and/or
fellowship program or pursuing a dental school degree, dental residency and/or fellowship
program
+ Not participating in another loan repayment program as of June 30, 2021
+ Practice in California/willing to relocate to practice in California
+ Be employed, self-employed or have a validated offer of employment by June 30, 2021
+ Willing to maintain a patient caseload comprised of a minimum of 30% Medi-Cal beneficiaries
and within 10% of the Medi-Cal patient caseload proposed in their application
Below is a Table of Eligible and Ineligible Loans:
Eligible Ineligible
Any outstanding U.S. government (federal, Educational loans in pursuit of other post-
state, or local) and US commercial (i.e., graduate degrees such as Master of Public
private) student loan for undergraduate or Health (MPH), Master of Business
graduate education obtained by the Administration (MBA), or Doctor of
applicant for school tuition, and Philosophy (PhD) are not eligible for the
reasonable educational expenses in Loan Repayment Program. Applicants
pursuit of their medical and/or dental may still apply if you have an MPH, MBA, or
degree. PhD; however, their educational loans in
In the name of the applicant
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APPLICATION INSTRUCTIONS
Obtained prior to the submission of the pursuit of those degrees are not qualifying
application to the Loan Repayment loans eligible for a loan repayment.
Program Parents PLUS loans
In good standing (not being in default); Personal lines of credit
deferment and forbearance are okay Loans subject to cancellation
Consolidated educational loans may be Loans in default
eligible, and they must clearly delineate
Credit card debt
the original loans and the degrees
conferred. They cannot be with another Promissory notes
person’s loan or with non-educational Loans outside of the U.S.
loans. Failure to provide this information
may result in ineligibility for the program.
Payments will be made in arrears after every one-year of service, upon verification of meeting program
requirements (i.e. active and unrestricted license, in good standing with the Medi-Cal program,
minimum 30% Medi-Cal caseload). Each annual payment will be 20% of the total award. As such, an
awardee who receives a loan repayment of a total of $300,000.00 and meets program requirements
would receive a $60,000.00 payment after each one year of service, for five years (see Table 3 below), while
an awardee who receives a loan repayment of a total of $100,000.00 and meets program requirements
would receive $20,000.00 after each one year of service, for five years (See Table 4 below). The Loan
Repayment Program award amount is based on the Current Total Payoff Balance of qualifying
educational debt and the applicant’s hours providing direct patient care, or up to a maximum amount of
$300,000.00. The total amount will be included in the contract for the awardee to review prior to the start
of the five-year contractual period. Awardees are responsible for keeping their educational loans in good
standing. Payments will be mailed directly to the awardee in check format after review of approval of
awardee’s Annual Report verifying Medi-Cal patient caseload in addition to other program requirements.
Table 3: Loan Repayment Funding Disbursement Assuming $300,000.00 Award
Funds disbursed after verification of Percentage of total
Amount
meeting program requirements awarded
After first year 20% $60,000.00
After second year 20% $60,000.00
After third year 20% $60,000.00
After fourth year 20% $60,000.00
After fifth year 20% $60,000.00
Note: Assumes all program requirements have been met. This is verified through review and approval of Semi-
Annual and Annual Reviews.
Loan Repayment Program Taxable Income Status: Payments made under the
National Health Service Corps or any state loan repayment or loan forgiveness program that is intended
to provide for the increased availability of health care services in underserved or health professional
shortage areas are excluded from gross income, effective for amounts received by an individual in tax
years beginning after December 31, 2008. Per the Internal Revenue Service (IRS), certain educational loan
repayment or loan forgiveness programs to help provide health services in certain areas are exceptions
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to cancellation of debt and therefore reportable but not taxable income. Applicants are advised to
consult with a tax advisor to address questions about whether this loan repayment is considered
reportable and/or taxable income. This response is not intended to provide tax or legal advice. Applicants
with questions regarding the taxable and/or reportable nature of this loan repayment should consult a
tax advisor.
Practice Support Grant: This section contains information for dentists applying to the
CalHealthCares Practice Support Grant.
Dentists may apply for either the Loan Repayment Program or the Practice Support Grant, not both. The
electronic application will ask dentists to choose an option. The Practice Support Grant provides up to
$300,000.00 to relocate, expand or establish a new practice in one of the target counties (as shown in
Step 8 of this document, under Electronic Application), in exchange for a ten-year service commitment.
Relocate means applicants will relocate their current practice to a target county. Expand means
applicants will expand their current practice by opening a new location within a target county. Establish
means applicants will establish a new practice within a target county.
Dentists applying for the Practice Support Grant are not required to have educational loan debt. Dentists
(Doctor of Dental Surgery or Doctor of Medicine in Dentistry) practicing general and/or specialty dentistry
are eligible to apply.
Below is the List of Applicant Requirements:
+ Have an unrestricted license and be in good standing with the Dental Board of California
+ Be an active enrolled Medi-Cal Dental provider without existing suspensions, disbarments or
revocations or have applied to DHCS to become an active enrolled Medi-Cal provider
+ Have graduated from dental school or residency program within the last fifteen (15) years (on or
after January 1, 2006); graduates of national and/or international schools of medicine are eligible
to apply
+ Not be currently participating in another loan repayment program or practice support grant as of
June 30, 2021
+ Practice in California/willing to relocate, expand or establish a new practice if they receive the
Practice Support Grant, in one of the target counties
+ Willing to maintain a patient caseload comprised of a minimum of 30% Medi-Cal beneficiaries
and within 10% of the Medi-Cal patient caseload proposed in their application
Assuming a funding request of $300,000.00, the funding disbursement is 10% ($30,000.00) after the
initial contract signing, 23% ($69,000.00) in year one and 67% ($50,250.00 each year) across the remaining
four years. The remaining five years will be spent monitoring the awardees to ensure compliance (See
Table 4 below). Awardees who breach their contract will be required to repay a portion of their award.
Details will be provided in the awardee contract.
Table 4: Practice Support Grant Funding Disbursement Assuming $300,000.00 Grant
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Percentage of total
When funds will be disbursed Amount
awarded
After initial contract signing 10% $30,000.00
After first year 23% $69,000.00
After second year 16.75% $50,250.00
After third year 16.75% $50,250.00
After fourth year 16.75% $50,250.00
After fifth year 16.75% $50,250.00
Note: Assumes all program requirements have been met. This is verified through completion of Semi-Annual and
Annual Reviews.
Practice Support Grant Taxable Income Status: Practice support grants are typically
considered reportable and taxable income. The information contained in this document should not be
considered tax advice. Applicants are advised to consult with a tax advisor to address questions about
whether this grant is considered reportable and/or taxable income.
PROGRAM REQUIREMENTS
Awardee is defined as an applicant who has been selected to receive the CalHealthCares award and who
has signed the program contract. Awardees may be considered in breach of their contract if they are
unable to comply with the terms of their contract. If an awardee does not meet the terms of their
contractual obligations, they may not be eligible for the annual payment.
Below is the List of Program Requirements Awardees are Expected to Comply with
Beginning July 1, 2021:
+ To complete any necessary training programs (i.e., formal schooling, residency and any applicable
fellowship)
+ Be employed, self-employed or have a validated offer of employment
+ Must be eligible to work in the United States for the terms of their contract
+ Practice in California
+ Willing to expand and open a new practice, relocate their current practice or establish a new
practice if awarded the Practice Support Grant, in one of the target countries ( Practice Support
Grant only)
+ Maintain a current and unrestricted license and be in good standing with the Medical Board of
California, Osteopathic Medical Board of California or Dental Board of California (may not be listed
in Medicaid bar list or the Medi-Cal suspended list)
+ To be an active enrolled Medi-Cal provider with DHCS and to remain in good standing without
existing suspensions, disbarments or revocations
+ Not be subject to a performance improvement plan (i.e., disciplinary action) from an employer
related to their standard of care
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+ Not enter another disqualifying loan repayment program or a practice support grant during
contractual period
+ Keep their educational loans in good standing and provide documentation satisfactory to PHC
demonstrating the awardee is in compliance with the terms of each applicable educational loan
agreement (Loan Repayment Program)
+ Have their patient caseload comprised of a minimum of 30% Medi-Cal beneficiaries and within
10% of the Medi-Cal patient caseload proposed in their application for a period of 5 years (Loan
Repayment Program) and 10 years (Practice Support Grant).
+ Submit Semi-Annual Reviews (SAR) and Annual Reviews (AR), in the form required by PHC,
demonstrating compliance with program requirements and their Awardee Agreement/contract.
This includes submitting Medi-Cal source documentation, which is official data typically
generated via billing or an EHR system, to support the Medi-Cal caseload percentage reported.
+ To cooperate with any audit undertaken by PHC or state agency regarding awardee’s compliance
with the program
+ To inform PHC in writing, within 10 business days, of any change in: mailing address, telephone
number, e-mail address, name of lending institution or any other change in circumstances
(including employment status, Medi-Cal participation, Medi-Cal caseload, loan status, lender
name or consolidation) impacting an awardee’s eligibility to receive or participate in the Loan
Repayment Program or the Practice Support Grant
Awardees will be required to submit SARs and ARs regarding compliance with program requirements
such as the active status of their employment, Medi-Cal patient caseload and the status of their
educational loans. Failure to comply with these requirements may result in a breach of contract. Those
who have breached their contract (i.e., defaults in educational loans, reduces hours of direct patient care
and/or whose caseload drops below the minimum of 30% of Medi-Cal beneficiaries) may not be eligible
for an annual payment. To view the SAR and AR documents applicants should visit our website at
www.CalHealthCares.org. DHCS will consider each breach of contract separately and individually. DHCS
has discretion to consider extenuating circumstances determining whether the awardee may remain in
the program.
Patient Caseload: This section elaborates on the following requirement: Maintain patient caseload
at a minimum of 30% Medi-Cal beneficiaries and within 10% of the Medi-Cal patient caseload as proposed
within the application for a period of 5 years (Loan Repayment Program) and 10 years (Practice Support
Grant).
For purposes of this program, a patient caseload may be defined as annual office visits, panel of patients,
payor mix, or time. Applicants do not need to be currently at 30% Medi-Cal to be eligible for the
CalHealthCares program. Awardees must maintain an individual patient caseload comprised of a
minimum of 30% Medi-Cal beneficiaries and within 10% of the Medi-Cal patient caseload proposed in
their application. The proposed Medi-Cal caseload is the percentage applicants will be able to meet, if
awarded. Per the mission statement, CalHealthCares is committed to increasing providers accepting
Medi-Cal patients by supporting and incentivizing physicians and dentists to increase participation in the
Medi-Cal program. The goal of the program is to increase access to care by Medi-Cal beneficiaries.
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The patient caseload section is worth 20 points of 50 points for the Loan Repayment Program and 20
points of 60 points for the Practice Support Grant.
The information submitted within the application should be considered auditable self-attestation – this
means that applicants will self-attest that they will be meeting the minimum 30% individual Medi-Cal
caseload and within 10% of the Medi-Cal patient caseload proposed within their application. This self-
attestation is subject to an audit. This information must be current and pulled from a reliable and
accurate source such as an electronic health records (EHR) or billing program. Awardees must maintain
an individual patient caseload comprised of a minimum of 30% Medi-Cal beneficiaries and within 10% of
the Medi-Cal patient caseload proposed in their application. Awardees will be required to submit
documentation to verify this requirement as well as describe how they calculated their existing Medi-Cal
caseload semi-annually for their SAR and AR. For each review period, awardees will be required to submit
Medi-Cal source documentation, which is official data typically generated via billing or an EHR system, to
support the Medi-Cal caseload percentage reported for that the given review period.
Therefore, it is important for applicants to speak with their supervisor, practice site and/or organization to
verify they are able to report this information and determine the process for tracking and reporting their
caseload. One should apply to the program with the mindset they consistently need to monitor their
own progress and take action if their Medi-Cal caseload percentages fall below the parameters set in the
awardee contract and by the program as described earlier in this section. Appendix E contains more
information on how to calculate the patient caseload.
Below is a list of how each approved definition is calculated:
+ Payor mix is determined by calculating the percentage of revenue or number of claims submitted
from each payor
+ Panel of patients is determined by calculating the number of patients a provider is responsible for
managing
+ Annual patient visits is determined by calculating the number of patients seen in a one-year
timeframe (patient encounters)
+ Practice time is determined by the amount of time you have spent with each patient
Payments will not be made if an awardee fails to meet the program requirements outlined above. All
awardees are required to have their patient caseload comprised of a minimum of 30% Medi-Cal
beneficiaries and within 10% of the Medi-Cal patient caseload proposed within this application. Awardees
who meet the minimum of 30% Medi-Cal beneficiaries but are not within 10% of their stated proposed
Medi-Cal percentage will be placed on a probationary period. To view the Probationary Period document,
applicants should visit www.CalHealthCares.org and go to the Awardee Resources page. An awardee
may be terminated from the program if there are two consecutive years in which they do not comply
with the terms of their contract. For example, if an awardee fails to meet the terms of their contract in
year one, they will not receive an annual payment for their first year in the program. They may remain in
the program and will be monitored for program compliance in future years and if they are able to meet
all program requirements for the second year, they will receive an annual payment for the second year. If
the awardee fails to meet the program requirements for the second year, the awardee may be
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terminated from the program. DHCS has discretion determining whether awardees may remain in the
program.
ELECTRONIC APPLICATION
Before You Apply: This section covers a few things applicants should be aware of prior to
accessing the online application.
Pre-Application Checklist:
+ Utilize the numerous following instructional resources to better understand the process for
applying and the program requirements, if awarded: read the Application Instructions (this
written manual), read the Applicant Checklist and watch the 2021 Application Cycle Webinar.
resources break the application down into step-by-step format.
+ Review infographic, Fact Sheet, and FAQs for their corresponding group (dentists or physicians)
on www.CalHealthCares.org.
+ Speak with their supervisor, practice site and/or organization to verify they are able to report this
information and determine the process for tracking and reporting their caseload, for the purpose
of submitting their SAR and AR, if awarded.
+ Collect Employment Verification Forms (EVF) from their direct supervisors for each practice site.
(Download from www.CalHealthCares.org.) Appendix B has more information on filling out the
EVF.
+ Loan Repayment Program Only: Obtain educational loan statements with Total Payoff Balance
amount. Appendix D contains more information on obtaining this statement.
+ Practice Support Grant Only: Create valid business plan detailing business relocation, expansion
or establishing a new location of an existing business in a target county. Appendix G contains
more information on what the business plan must include.
Applicants should keep in mind that this is a very competitive program. Funding is approximate and
applying is not a guarantee of award. The scoring criteria can be viewed by accessing Appendix F. DHCS
shall make the final determination on who is awarded. PHC has convened an Advisory Council to make
recommendations to DHCS.
Using and Navigating the E-App: This section provides an overview of the electronic
application and tips on navigating through the different pages.
Applications, along with supporting documents, are submitted electronically and will not be accepted
separately or in hard copy form. Each applicant must create an individual account with a username and
password. Returning applicants may use their previous username and password or can create a new
account. Returning users will not be able to see their previous application. An applicant must register an
account to view and complete the application. The electronic application link will go live on
www.CalHealthCares.org on January 18, 2021.
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Applicants are expected to fill out the required sections completely (the application will not allow
them to move on until they do), as well as submit additionally requested documentation in
complete format, without missing fields. If the applicant does not understand one or more fields, it
is their responsibility to contact the program (“Getting Questions Answered” provides contact
information). Otherwise, their application will be considered incomplete and they may be deemed
ineligible.
The following sections provide a step-by-step view of the questions on the CalHealthCares electronic
application with screenshots and a corresponding description for each section. To optimize navigation of
this instruction manual, CalHealthCares has also created a color-coded key based on the track the
applicant is applying with. There are 5 different tracks as shown below:
Applies to all tracks
Current Physician Resident or Physician Fellow
Physician
Current Dental Student or Dental Resident
Dentist applying to Loan Repayment Program
Dentist applying for Practice Support Grant
Once applicant logs in, the following landing page appears:
Applies to all tracks
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Applicants may watch the video for help with navigating the technical aspects of the application. Please
make sure to read the information on the program, as well as read and check off the individual
statements.
The application contains tabs for the 11 steps and a warning sign appears at the top of each page of the
application emphasizing that the applicant must meet all program requirements for the duration of the
contract, if awarded, in order to maintain program eligibility and receive an annual payment:
Applies to all tracks
Current Physician Resident or Physician Fellow
Physician
Current Dental Student or Dental Resident
Dentist applying to Loan Repayment Program
Dentist applying for Practice Support Grant
At the bottom of each page of the application is more information, numbered one through four.
Applies to all tracks
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Additionally, at the bottom of each page of the application is CalHealthCares contact information.
Applies to all tracks
Applicants will not be allowed to move forward to the next step in the application without completing all
mandatory fields. They can always go back to previous steps if they need to make a correction.
Step 1 – Eligibility: This section contains program eligibility requirements and questions about
additional loan repayment programs you may be participating in.
If applicant would like to view a preview of the entire application for a given track, they can select the
button, “view preview” (as shown below), and it will take them to a pdf of the application.
Applies to all tracks
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Applicant should select one of five tracks pertaining to them. Applicants who use the incorrect track (ex:
physician residents using the physicians track instead of the physician residents or physician fellows
track) may be deemed ineligible and as a result will be disqualified from the CalHealthCares program.
The selected track chosen by the applicant will impact the format and questions of the entire application.
If applicant changes the track after filling out some of the steps, they may have to re-enter the
information. As a reminder, dentists may apply for either the Loan Repayment Program or the Practice
Support Grant. Eligible dentists may not apply for both – the electronic application will ask eligible
dentists to choose the option for which they are applying.
Applies to all tracks
Then, a checklist of attestations will pop-up corresponding to the selected track. Applicant should read
and check off all the attestations prior to continuing.
Page 15 of 83 Rev. 01/18/2021
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Current Physician Resident or Physician Fellow
Physician
Current Dental Student or Dental Resident
Page 16 of 83 Rev. 01/18/2021
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Dentist applying to Loan Repayment Program
Dentist applying for Practice Support Grant
The information provided should be considered auditable self-attestation. This means applicants will self-
attest they are able and willing to comply with the program requirements and any other inquiry by PHC,
DHCS or state agency. Applicants and awardees will be asked to provide documentation regarding but
not limited to the following: at the time of the SAR, AR and other potential audits, to ensure compliance
with the program requirements:
+ Current medical and/or dental license by the Medical Board of California, Osteopathic Medical
Board of California and/or Dental Board of California
+ Proof of employment
+ Evidence of awardee’s patient caseload comprised of a minimum of 30% Medi-Cal beneficiaries
and within 10% of the proposed Medi-Cal patient caseload as noted within this application
+ Proof of current educational loan debt. Loan statement should include applicant’s name, address,
date and Total Payoff Balance. Applicant’s Total Payoff Balance should include the amount it
would take to pay off their loan, including interest. Applicants will be held to the payoff amount
Page 17 of 83 Rev. 01/18/2021
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they provide. Any inconsistencies on the lender statement and the application can result in the
following: reduction in award amount, incomplete application, or applicant found not eligible.
+ Proof of enrollment as a Medi-Cal provider
+ Proof of contracts with Medi-Cal managed care plans and/or fee-for-service Medi-Cal
+ Proof of agreements with safety net providers such as designated public hospitals and/or
Federally Qualified Health Centers (FQHC)
Next is a question about other loan repayment programs the applicant may be currently participating in.
Applies to all tracks
The options are yes or no. Selecting yes prompts the following drop-down menu:
Applicants currently participating in another disqualifying loan repayment program who will not
complete their service obligation by June 30, 2021 with that program are not eligible to apply. This may
include employer-sponsored, local, regional, state and/or national loan repayment programs. Applicants
in this situation are welcome to apply to the CalHealthCares Loan Repayment Program after successfully
completing their other loan repayment program.
The following message appears for those who are not currently eligible to apply due to participation in
another loan repayment program:
Page 18 of 83 Rev. 01/18/2021
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Applies to all tracks
The options are yes or no. Selecting yes prompts the following drop-down menu and additional
questions:
Participating and successfully completing a loan repayment program in the past will not impact an
applicant’s eligibility.
This page is critical. Applicants must check off they are eligible to apply based on the criteria set forth. If
applicants do not check off all boxes, the electronic application will not allow them to continue further.
Applicants will receive an error message and have the opportunity to explain why they think they are still
eligible to apply, as shown below.
Applies to all tracks
Page 19 of 83 Rev. 01/18/2021
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PHC will consider each request for consideration separately and individually and make a
recommendation to DHCS for consideration. DHCS has discretion to consider extenuating circumstances
in determining whether an applicant may be eligible for the program.
Step 2 – Communications: This section contains questions on communications/outreach and
whether the applicant is new or returning.
Applies to all tracks
If applicant has heard about the program through multiple channels of communication, they should
select the option that best describes their initial exposure to the program. Responses will help PHC with
future marketing and outreach efforts. If applicant selects “Other,” they will be prompted to type in their
response.
Page 20 of 83 Rev. 01/18/2021
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Applies to all tracks
If applicant selects “Other,” “Presentation,” “Specialty Society,” or “Professional Association,” they will be
prompted to type in their response.
If applicant selects “Email” or “Social Media,” the following pop-up menu appears, based on the selection.
Applicants should select the option representing best outreach methods for future CalHealthCares
cycles.
Lastly (for Step 2), the applicant should indicate if they are a new or returning applicant. They may select
both cohorts if they have applied twice. Applicants are still eligible to apply to the program even though
they may have applied previously if they still meet program requirements.
Applies to all tracks
Page 21 of 83 Rev. 01/18/2021
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Applicant should click “next” if ready to move on to the next page, or “back” if they would like to return to
the previous page. These buttons appear on slides 2 through 10 of the application.
Step 3 – Applicant Information: This section contains information about the applicant (i.e.,
contact information, demographics, National Provider Index Number (NPI), languages used with
patients, specialty.
First, fill out contact and demographic information.
Applies to all tracks
➢ Applicant Information: This section is for contact information and other demographic information.
Applicant should ensure information for address, telephone number and email are accurate as
PHC will use this information to contact applicants regarding award status, contracts, payments,
etc.
Page 22 of 83 Rev. 01/18/2021
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➢ Name: Applicant should provide their first, middle, and last name as it appears on their medical,
osteopathic or dental license. First and last name is mandatory; middle name is optional within
the application, as some applicants may not have a middle name.
➢ Primary Address, Primary Telephone Number, and Primary Email: Applicant should provide the
preferred primary address and telephone number. PHC will use these contact methods if there is
a need for additional information to determine the applicant’s eligibility and/or to reach out to the
applicant if they are awarded.
➢ Secondary Telephone Number and Email: Applicant should provide a back-up telephone number
and email. PHC will use these secondary contact methods if there is a need for additional
information to determine applicant’s eligibility and/or to reach out to the applicant if they are
awarded, if PHC cannot reach the applicants and awardees at their primary contact methods.
➢ Sex, Gender, and Race/Ethnicity: Applicant should select option that best describes them.
Demographic information such as gender, date of birth and race/ethnicity will not be used to
determine applicant’s eligibility for funding. This information is collected solely for statistical
purposes.
Next, applicant will need to provide License Number and a 10-digit NPI. If an applicant does not yet have
an NPI or license number, they should input all 1’s.
Current Physician Resident or Physician Fellow
Physician
Selecting “Medical license” will trigger the following window:
Page 23 of 83 Rev. 01/18/2021
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Selecting “Osteopathic license” will trigger the following window:
Current Dental Student or Dental Resident
Dentist applying to Loan Repayment Program
Dentist applying for Practice Support Grant
➢ Current License Number: Applicants will be asked to provide their medical license information
(letter followed by up to a six (6) digit number), osteopathic license number (up to a five (5) digit
number), or dental license number (up to a six (6) digit number).
➢ NPI: Applicants must provide their ten (10) digit NPI.
Next, there is a language section. Applicant should click on “Add language.”
Page 24 of 83 Rev. 01/18/2021
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Applies to all tracks
Applicant can select language(s) from the drop-down list. They should provide any languages spoken at
work in addition to English. These must be spoken directly to the patient without the use of
translator/interpreter services. Languages spoken at work will be verified through the Employer
Verification Form (EVF), so applicants should ensure the language they input in this section matches the
“additional language” section on the EVF. Upon selecting language, applicants should also provide the
corresponding percentage range for each language, as a ratio out of total time speaking all languages,
including English.
If option does not apply to applicant, they must select the option “None.” The field may not be left blank.
Page 25 of 83 Rev. 01/18/2021
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