Medicaid Coverage of Community Health Worker Services

Authors: Medicaid and CHIP Payment and Access Commission
Year: 2022
State: NatDoc: National Document
Website link:
Publicly Available: Yes
Certification: Administration - certification boards state health departments etc., CHW role scope of practice, Competencies, Funding of certification, Process and development, Role of state government, State input in process, Training and training programs
Evidence Generation: Documentation of how CHWs can work within care teams
Policy: General other, Legislative language, MCO contract language and reimbursement models, National guidance especially in new policy areas
Sustainable Financing: CMS and CDC engagement from a national level, Engaging state partners in general, Expand evidence base, How to engage and work with Medicaid, Including community-based CHWs, Billing/CPT codes, Education to HC orgs on payment options bundled etc., MCO or bundled payment reimbursement models, Reimbursement TA for FQHCs Medicaid etc., Documentation of how CHWs can work within care teams
Workforce Development: CHW training programs (not cert.)

Interest among federal and state policymakers and other Medicaid stakeholders in expanding Medicaid coverage of services provided by community health workers (CHWs) has been growing given the potential role of CHWs in helping Medicaid beneficiaries access services. CHWs are individuals with strong ties to the communities they serve and who provide a range of services addressing the health and social needs of their clients. A review of publicly available information conducted by MACPAC in 2021 identified at least 21 states that authorize Medicaid payment for certain CHW services, in their state plan or under managed care arrangements. In most cases, state Medicaid programs allow coverage of a limited range of CHW-provided services or limit CHW services to specific populations. Because of their community relationships, CHWs can facilitate connections and greater trust between the community and health care systems. They may be members of communities that are typically underrepresented in health care settings or may be specifically qualified to provide culturally competent care. CHWs are often seen as having an important role in promoting health equity and helping to address disparities, however, Medicaid coverage of CHW services is limited. CHW services may include health promotion and education, patient outreach and follow-up, assistance in navigating the health care system, translation and interpretation services, and care coordination and case management. Training and education requirements vary widely depending on their specific role, employer, and other factors. This issue brief begins with an overview of the various types of CHWs and the services they provide. It then reviews selected studies documenting the effects of CHW programs on health outcomes and costs. The brief describes state approaches to covering CHW services in Medicaid, including the various authorities they use to provide Medicaid payment, the services they cover, the populations served, and training and certification requirements.

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