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November 20, 2025
Toolkit
Annie Cloke
Margarita Hart
Janée Tyus
Dawn Alley
Shreya Kangovi
Publication
Jul 23, 2026
Jul 15, 2026
Jul 14, 2026
Developing Sufficient Rates. As of January 2025, there was significant variation in Medicaid payment rates for CHW/P/CHR services covered by state fee-for-service (FFS) programs, ranging from over $18 to $50 per 30 minutes.18 For comparison, the average national rate for 30 minutes of Medicare Community Health Integration services provided by a CHW is $48.52 in 2025.19
An analysis of state Medicaid FFS and managed care reimbursement for CHW/P/CHR services found that payment rates need to be higher to support the financial viability of CHW/P/CHR programs. The study recommended a minimum FFS rate of $53.24.20
As of June 2025, California was seeking SPA approval to align Medicaid payment for CHI services with Medicare rates, which are higher than Medicaid payments for other CHW/P/CHR services covered by the state.21
States with SPAs authorizing CHW/P/CHR reimbursement have largely established FFS payment rates. Some states have included requirements for integration of CHW/P/CHR services into managed care contracts.
Regardless of how CHW/P/CHR services are paid (e.g., FFS or MCO), the following principles should guide rate development. Rates must:
Considerations for federally qualified health centers (FQHCs). FQHCs are a large employer of CHW/P/CHRs in many states and a critical access point for many Medicaid beneficiaries. As states develop CHW/P/CHR reimbursement rates, CHW/P/CHR services provided by FQHCs must be accounted for either in the state’s FQHC prospective payment system (PPS), through billing codes outside of the PPS rate, or through an alternative approach (e.g., an alternative payment model).
Glossary
Delivery location and mechanism: Where and through what mechanism covered CHW/P/CHR services can be delivered (e.g., clinic-based, home- or community-based, face-to-face, telephonically, via telehealth).
Documentation requirements: What information CHW/P/CHRs need to document for reimbursement purposes when providing covered CHW/P/CHR services.
Duration of services/frequency limits: Frequency of covered CHW/P/CHRs services (daily, monthly, annually).
Eligible population: Population eligible to receive CHW/P/CHR services.
Provider billing: Which providers can bill/submit claims for CHW/P/CHR services.
Provider qualifications and requirements: Individual CHW/P/CHR certification or CHW/P/CHR program/employer accreditation requirements.
Services covered: CHW/P/CHR services the state Medicaid program reimburses for.
Service initiation: Which providers can initiate CHW/P/CHR services.
Supervision: Supervision requirements for CHW/P/CHRs delivering covered services.
18. Based on reimbursement for code 98960 (one patient). Department of Health, State of Louisiana, Professional Services, Lab, X-Ray, Radiology and ASC Fee Schedule. Effective 7/1/25. Accessed October 10, 2025. New Mexico Health Care Authority, Community Health Workers and Community Health Representatives Fee Schedule. Effective 1/1/25. Accessed October 10, 2025.
19. National average physician fee schedule payment level for HCPCS code G0022. CMS. License for use of current procedural terminology, fourth edition (“CPT®”). https://www.cms.gov/medicare/physician-fee-schedule/search Y=0&T=4&HT=0&CT=2&H1=G0022&C=1&M=5. Accessed September 25, 2024.
20. Basu S, Patel SY, Robinson K, et al. Financing thresholds for sustainability of community health worker programs for patients receiving Medicaid across the United States. J Community Health 2024;49:606–634. https://doi.org/10.1007/s10900-023-01290-w.
21. California SPA 25-0016 Public Notice and SPA 25-0016 Pending. Accessed October 14, 2025. Medi-Cal Rates | Medi-Cal Providers
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