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November 25, 2024
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Annie Cloke
Margarita Hart
Janée Tyus
Dawn Alley
Shreya Kangovi
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1. (Definition) A community health worker, promotore, and community health representative (CHW/P/CHR) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.
2. (Population Eligible for CHW Services)
(Option 2a. Prioritizes Access) CHW/P/CHR services are available to all Medicaid beneficiaries.
(Option 2b. Prioritizes Rising Risk Population) CHW/P/CHR services are available to beneficiaries with at least two chronic conditions or at least one chronic condition and one identified health-related social need.
3. (Services Covered)
(Option 3a. Prioritizes Comprehensive Evidence-Based Services) The following services are covered when performed by CHW/P/CHRs:
(Option 3b. Prioritizes Defined Service Package) Covered CHW/P/CHR services include system navigation, health promotion, and clinical support. These services include but are not limited to:
4. (Requirements for Billing Entity)
(Option 4a. Prioritizes Evidence and CHW/P/CHR Work Environment) CHW/P/CHR program must meet state-approved accreditation standards that consider, at a minimum:
(Option 4b. Prioritizes Ease of Requirement) CHW/P/CHR program must employ individuals who have been trained on CHW core competencies, including relationship building and system navigation.
5. (Service Initiation & Supervision)
(Option 5a. Prioritizes Access & Flexibility) This standing order authorizes CHW/P/CHRs and agencies that provide CHW/P/CHR services to provide covered CHW/P/CHR services to eligible individuals.
(Option 5b. Prioritizes Access & Provider Relationships) A Medicaid-enrolled provider may establish a standing order with a contracted community-based organization that allows CHW/P/CHRs to provide covered CHW/P/CHR services to eligible individuals.
(Option 5c. Prioritizes Role of the Provider) CHW/P/CHRs must deliver services under the general supervision of a Medicaid-enrolled, licensed provider who orders CHW/P/CHR services for eligible individuals. The CHW/P/CHR may be external to, and under contract with, the practitioner or their practice, such as through a community-based organization.
6. (Delivery Location & Mechanism)
(Option 6a. Prioritizes Access) Services may be delivered in person in the clinic, in person in the home or community, telephonically, or via telehealth. Service time billed must be for either direct contact (in person, telephonically, or via telehealth) with a beneficiary or for services performed as part of an individual’s care plan even if the individual is not present.
There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of the service, but remains the focus of the service.
(Option 6b. Prioritizes Access, Favors in Person) Services may be delivered in person in the clinic, in person in the home or community, telephonically, or via telehealth. Service time billed must be for either direct contact (in person, telephonically, or via telehealth) with a beneficiary or for services performed as part of an individual’s care plan even if the individual is not present.
Payment rates may differ based on modality of delivery.
7. (Provider Billing)
(Option 7a. Prioritizes Empowering CHWs) CHW/P/CHRs may enroll as a CHW/P/CHR provider to be able to provide and bill for services for Medicaid beneficiaries.
(Option 7b. Prioritizes Role of the Provider) CHW/P/CHR services are reimbursed incident to the Medicaid-enrolled, licensed provider providing general supervision to the CHW/P/CHR.
The CHW/P/CHR may be external to, and under contract with, the practitioner or their practice, such as through a community-based organization.
8. (Duration of Services/Frequency Limits)
(Option 8a. Prioritizes Access and Cost Containment) Covered CHW/P/CHR services are limited to 4 units (or 2 hours) per day, per beneficiary. Covered CHW/P/CHR services are limited to 24 units (or 12 hours) per month, per beneficiary.
(Option 8b. Prioritizes Access) There is no monthly or annual limit to the number of allowed CHW/P/CHR visits/hours per beneficiary.
9. (Documentation) CHW/P/CHRs are required to document the amount of time spent with the patient and the nature of the activities.