Community Health Workers & Medicaid: Advancing Health Equity Depends on State Implementation

As National Community Health Worker Awareness Week approaches at the end of August, we want to take stock of the advances in Medicaid’s role in financing community health worker (CHW) services and the road ahead. CHWs have a long history of supporting community public health by engaging individuals in communities that the traditional health system has historically left out. This can mean trusted allies to help navigate the complex health care system, increased trust in health providers that can translate to earlier access to needed care, and more.

States are increasingly and proactively taking steps to reimburse preventive services in their Medicaid programs by non-medical, often community-based, providers such as CHWs or doulas – an opportunity broadened by the Affordable Care Act (ACA). This is a great advancement for improved access to preventive care, especially in reaching communities of color or other historically marginalized groups that may not trust the traditional health care system. However, the design of state CHW programs – from reimbursement rates to CHW billing capacity – raises important questions about ensuring the new provider type successfully reaches those who may benefit the most. What specific services should CHWs be allowed to provide? How can state Medicaid help to grow the CHW workforce without adding burdensome red tape in the health care billing practices that add rules and possible barriers to payment? Will Medicaid managed care organizations be required or incentivized to contract directly with community-based organizations to ensure CHWs? States will be faced with these and many more questions as they seek to implement CHW and other community-based preventive care providers that differ from clinical care providers.

How do states reimburse CHWs in Medicaid?

There are a variety of options for covering CHW services. States have relatively new flexibility to cover a wide range of services using a state plan amendment (SPA) under the preventive services authority (42 CFR 440.130(c)). The ACA included a relatively small but significant change detailed in 2013 guidance that made this possible: preventive services previously needed to be “delivered by a physician or other practitioner of the healing arts,” but now need only to be “recommended” by a licensed practitioner. This change allowed a fuller spectrum of providers, including CHWs, to deliver preventive services, such as health screenings and referrals.

Several states including Rhode Island, South Dakota, and California have already taken advantage of the preventive services authority in their SPAs. Two new states have the opportunity to use the same pathway: Nevada, as required by recently enacted SB117 or Michigan if the state decides to pursue a SPA when the FY24 Health and Human Services Budget (SB190) passes the state House of Representatives.

CHWs also have potential to address the multiple health crises facing families: maternal health, mental health, and historic and systemic racism. As states seek new tools to address the maternal health crisis and support postpartum parents and their children during the first year following a birth, CHWs offer a new way to help reach families during a highly vulnerable period of transition. Minnesota reimburses CHWs in Medicaid to provide home visiting services.

There is more potential for CHWs to support children and families well before a risk factor or crisis arises. For young children in particular, early identification and intervention is key to addressing health conditions early. New York enacted S4007 in May to allow Medicaid reimbursement for certain high-risk populations, including support services for care management for children under the age of 21. CHWs can also be an important way to identify issues before risk factors arise by being a part of pediatric primary care teams to support families during and between well-child visits. Washington state is testing CHWs in pediatric practices to improve early relational health, the foundational parent-child relationship critical to positive early development.

From Potential to Progress: Implementation Can Make or Break Success

States can only meet the potential for CHWs with careful attention to implementation. A new report from Partners in Health – United States outlines key principles that states can use to support the use of Medicaid funding for CHWs in an equitable manner. These principles include covering a wide range of CHW services, ensuring the inclusion of CHWs employed by community-based organizations, promoting CHW leadership in policy decision-making processes, adopting payment models that value CHWs, and growing the CHW workforce.  A number of states have taken similar approaches to implement doula benefits in Medicaid.

As we highlighted previously, Connecticut was considering legislation earlier this year for Medicaid reimbursement for CHW services that in June passed the state’s House of Representatives unanimously and was approved by the Senate. The Community Health Workers Association of Connecticut and Health Equity Solutions spent a year talking with CHWs to ultimately shape the legislation’s language. Now, the state’s Department of Social Services must design and implement Medicaid reimbursement. However, the legislation does not designate a date for when reimbursements must begin. While time should not be wasted or deliberately delayed, Connecticut’s new charge offers an important opportunity for the state to carefully apply some of the principles outlined by Partners in Health, especially the continued inclusion of CHWs in policy decision-making. As Connecticut and other states continue to pursue CHW reimbursement in their Medicaid programs, keeping an eye toward equitable implementation will be vitally important for quality, reach, and workforce sustainability.