\ X Summary of Medicaid State Plan Amendments for CHCF Community Health Workers AUGUST 2022 The chart below summarizes state plan amendments (SPAs) that incorporate community health workers (CHWs) into state Medicaid programs. While other SPAs incorporate CHWs into Medicaid through targeted pathways for specified populations such as health homes and targeted care management, the following SPAs authorize CHWs to serve a broad Medicaid population. STATUTORY AUTHORITY COVERED SERVICES CALIFORNIA (approved: July 26, 2022; effective: July 1, 2022) Preventive services 42 CFR 440.130(c) and 42 CFR 447 The SPA defines CHW services as "preventive health services to prevent disease, disability, and other health conditions or their progression; to prolong life; and to promote physical and mental health and efficiency."' Under the SPA, CHW services related to preventive health include these: >» Health education, consistent with established or recognized health care standards, to promote health or to address barri- ers to care. > Health navigation to assist enrollees to "access health care, understand the health care system, or engage in their own care; connect to community resources to promote a beneficiary's health, address health care barriers or address health-related social needs."? » Screening and assessment to identify the need for services."? » Individual support or advocacy. "Violence prevention services include all CHW services listed above."* Covered services: » May be provided in an individual or group setting. > "Must be recommended by a physician or other licensed practitioner of the healing arts within their scope of practice under state law."® » "Must be supervised by a Medi-Cal enrolled community- based organization, local health jurisdiction, licensed provider, hospital, or clinic, as defined in 42 CFR 440.90."6 Noncovered services. The SPA outlines specific services not covered, including clinical case/care management that requires a license, personal care / homemaker services, transportation, and respite care, among others. CHW QUALIFICATIONS "CHWs must have lived experience that aligns with and provides a connection between the CHW and the community being served."" CHWs can qualify to provide preventive services through one of the following pathways: » Certificate of completion of a curriculum - that includes field experience - and attests to demonstrated skills/practical training in: Communication Interpersonal and relationship building Service coordination and navigation Capacity building Advocacy Education and facilitation Individual and community assessment Professional skills and conduct Outreach Evaluation and research Basic knowledge of public health principles and social determi- nants of health > Demonstrated work experience of at least 2,000 hours as a CHW in paid or volunteer positions within the previous three years and demonstrated skills and practical training as a CHW (in the areas specified above in the certificate pathway). CHWs qualifying through the work experience pathway must earn a certification of completion of a curriculum within 18 months of the first CHW visit to a Medi-Cal enrollee. The CHW may provide services without a certificate for no more than 18 months. » Violence prevention training. "For individuals providing CHW violence prevention services only, a Violence Prevention Professional Certification issued by Health Alliance for Violence Intervention or a certificate of completion in gang intervention training from the Urban Peace Institute."? Six hours of continuing education annually is required. REIMBURSEMENT / BUDGET "For dates of service on or after July 1, 2022, reimbursement rates shall be the lowest of the follow- ing: >» The amount billed, » The charge to the general public, or > 80% of the lowest maximum allowance established no earlier than July 1, 2022, by the federal Medicare program for the same or similar service." Budget impact when submitted: > FFY 2022: $841,944 > FFY 2023: $5,521,769 STATUTORY AUTHORITY COVERED SERVICES INDIANA (approved: November 28, 2018; effective: July 1, 2018) Medical or other remedial care provided by licensed practitioners 42 CFR 440.60 The SPA states "reimbursement is available for medically necessary services provided by a CHW within the scope of the applicable certification program" and within the scope of practice of the supervising licensed practitioner (e.g., health services provider in psychology, advanced practice nurse, physician assistant, podiatrist, or chiropractor)." "Supervision of the certified CHW is included in the scope of practice for each supervising licensed practitioner." Covered services include: » Diagnosis-related patient education » Facilitation of cultural brokering between a member and the member's health care team » Health promotion education > Direct preventive services or services aimed at slowing the progression of chronic diseases Noncovered services include "insurance enrollment and 'navigator' assistance; case management/care coordination; arranging transportation or providing transportation for a member to and from services; and direct patient care outside the level of certification an individual has attained."" CHW QUALIFICATIONS The CHW must be employed by the billing provider, and the billing provider must maintain documentation of the certification for the individual providing the CHW services.'5 Indiana Medicaid recognizes certification from specified entities. RE|MBURSEMENT / BUDGET According to additional guidance, the supervising licensed practi- tioner can bill for the CHW services at 50% of the resource- based relative value scale for the following current procedural terminology (CPT) codes related to health education: > 98960 > 98961 > 98962 Services must be provided face-to-face with the member, individually or in a group, in an outpatient, home, clinic, or other community setting. Services are limited to 4 units (or 2 hours) per member, per day or 24 units (or 12 hours) per member, per month. Budget impact when submitted: > FFY 2018: $5 > FFY 2019: $20 Califomia Health Care Foundation www.chcef.org 2 STATUTORY AUTHORITY COVERED SERVICES LOUISIANA (approved: May 23, 2022; effective: January 1, 2022) Medical or other remedial care provided by licensed practitioners 42 CFR 440.60 The SPA authorizes services provided to Medicaid enrollees by a qualified CHW. "In order to receive CHW services, a beneficiary must have: » Diagnosis of one or more chronic health conditions including behavioral health; » Suspected or documented unmet health-related social need; or » Pregnancy." Covered services include: » Health promotion and coaching including assessment and screening for health-related social needs, goal-setting / action planning, on-site observation of enrollees' living situations, and providing information/coaching in an individ- ual or group setting. » Care planning with an enrollee's care team. » Health system navigation and resource coordination including helping to engage, re-engage, or ensure follow-up in primary care / routine preventive care, adherence to treat- ment plans and self-management of chronic conditions."® Coverage limitations on CHW services include:" » Up to 2 hours per day and 10 hours per month per enrollee. » Services are covered "incident to" the supervising physi- cian, advance practice registered nurse (APRN), or physician assistant (PA). » Services must be ordered by a physician, APRN, or PA with an established clinical relationship with the enrollee. > Services must be rendered under the general supervision of a physician, APRN, or PA. » There are no site restrictions on where services may be delivered. » Two-way video and audio transmission is permissible. » Group services may not exceed eight unique enrollees at once. Noncovered services include insurance enrollment and naviga- tor assistance; case management/care coordination; directly providing transportation for an enrollee to and from services; and direct patient care outside the level of training a person has attained." CHW QUALIFICATIONS A qualified CHW is an individual who: » "Completed a state-recognized training curricula approved by the Louisiana CHW Workforce Coalition; or » Has 3,000 hours of documented work experiences as a CHW."2" RE|MBURSEMENT / BUDGET Medicaid will reimburse for CHW services provided to qualified enrollees by qualified CHWs." Budget impact when submitted: > FFY 2022: $85,292 > FFY 2023: $162,129 Summary of Medicaid State Plan Amendments for Community Health Workers www.chcf.org 3 STATUTORY AUTHORITY COVERED SERVICES CHW QUALIFICATIONS REIMBURSEMENT / BUDGET MINNESOTA2? (Minnesota Medicaid has covered CHW services since 2009) Unknown While Minnesota statute states that the "Medical Assistance (MA) program covers care coordination and patient educa- tion services provided by a CHW if the CHW has received a certificate from the Minnesota State Colleges and Universities System approved community health worker curriculum," currently, the only billable services provided by a CHW are diagnosis-related patient education services under the supervi- sion of a physician, dentist, APRN, certified public health nurse, mental health professional, or registered nurse working for an enrolled organization." Coverage requirements include: > Supervising provider "must order the patient education service(s) and must order that a CHW provides the service(s). > Service involves teaching the patient how to self-manage his or her health or oral health effectively in conjunction with the health care team. > Provided face-to-face with the member (individually or in a group) in an outpatient, home, clinic or other community setting. » Patient education plan or training program is consistent with established or recognized health or dental health care standards." Noncovered services include social services such as enroll- ment assistance or case management. Documentation requirements include: > Member's record: » An order for service, specifying the number of units ordered, whether group or individual services, and signed by an authorized provider from an enrolled organization. » "The patient education plan or training program used by the CHW." » "Periodic assessment of the member's progress and need for ongoing CHW services.""" > Documentation of: » "Date of service. » Start and end time for the service. » Whether the service was group or individual and if group, number of patients present, summary of the session's content, and the CHW's signature and printed name."* For services to qualify for reimbursement, CHWs must: > Have a valid certificate from the Minnesota State Colleges and Universities documenting completion of an approved CHW curriculum. > Inform the Minnesota Department of Human Services of their affili- ation with an approved supervising provider type by completing a required screening and enrollment process initially and once within every five years to maintain their enrollment. > Have a National Provider Identifier (NPI) or Unique Minnesota Provider Identifier. > Enrolled CHWs are considered a non-pay-to provider but must be listed on the claim as the person who rendered the CHW services. An eligible billing provider must submit claims for the render- ing CHW's services under the following CPT codes related to self-management education and training, face-to-face: > 98960, 1 patient > 98961, 2-4 patients > 98962, 5-8 patients > For groups with more than 8 patients, use 98962 with the U9 modifier Reimbursement limitations include: > Providers may bill in 30-minute units » No more than 4 units per 24 hours » No more than 24 units per member per calendar month Eligible billing providers include:*° > APRN > Clinic > Community health clinic > Critical access hospital > Dentist > Family planning agency > Federally Qualified Health Center (FQHC) Hospital Indian Health Service facility Mental health professional Physician Public health nurse clinic vVvvvvvyy Rural health clinic > Tribal health facility Budget impact when submitted: Unknown Califomia Health Care Foundation www.chef.org 4 STATUTORY AUTHORITY COVERED SERVICES OREGON (approved: September 20, 2012, effective: August 1, 2012) CHWs/ In 2012, Oregon added CHWs, peer wellness specialists, Doulas personal health navigators, and doulas as nontraditional health (2012): care workers to perform services within the scope of practice Medical of the supervising practitioner included in the state plan. For or other CHWs, the supervising licensed health care professionals remedial care includes physicians, certified nurse practitioners, physician provided assistants, PhD psychologists, PsyD psychologists, LCSW social by licensed workers, and licensed professional counselors. Doulas could be Practitioners supervised only by physicians and certified nurse practitioners." 42 CFR 440.60 "Eligible services include self-care and self-management train- ing, counseling in prevention or risk-factor reduction, tobacco use cessation counseling, alcohol or substance use screening, home visits, and activity therapy related to the care and treat- ment of a patient's disabling mental health problems." In 2017, Oregon moved the statutory authority for coverage of doulas in Medicaid from "medical or other remedial care provided by licensed practitioners" to "preventive services."* CHW QUALIFICATIONS To be eligible to provide services and for reimbursement of those services, CHWs must be certified and registered with the Oregon Health authority. To be certified as a CHW, a person must complete an approved training program (a work experience pathway expired June 30, 2021) and:* » Be at least 18 years old » Not be listed on the Medicaid provider exclusion list > Have successfully completed all training requirements for certification » Submit all required documentation and complete an application > Pass a criminal background check > Complete oral health training > Complete 20 continuing education units for recertification RE|MBURSEMENT / BUDGET CHWs:5 > Must register with the Traditional Health Worker Registry, obtain an NPI, and enroll as an Oregon Medicaid provider. » Are enrolled as nonpayable rendering providers. > Must work and bill under the supervision of a licensed provider. The billing provider must be a clinic or supervising medical provider. Billable procedure codes for CHW services in Oregon Medicaid can be found at: www.oregon.gov (PDF). Budget impact when submitted (CHWs): » FFY 2012: ($36,636) » FFY 2013: ($220,018) Summary of Medicaid State Plan Amendments for Community Health Workers www.chcf.org 5 STATUTORY AUTHORITY COVERED SERVICES RHODE ISLAND (approved: May 23, 2022; effective: July 1, 2021) Preventive The SPA defines CHW services as "a preventive health service services to prevent disease, disability and other health conditions or their progression; to prolong life; and/or to promote physical ee and mental health and efficiency."* Covered CHW services, within the CHW scope of practice, include:" >» Health promotion and coaching including assessment and screening for health-related social needs; setting goals / action planning; providing information/coaching. > Health education and training, using established training materials, to prevent disease, disability, and other health conditions or their progression; to prolong life; and/or to promote physical and mental health and efficiency. » Health system navigation and resource coordination services include ensuring patient-led follow-up in care, medication and treatment plan adherence, and self-manage- ment of chronic conditions by assisting to access covered services and other relevant community resources. » Care planning with interdisciplinary care team. "Services must be recommended by a licensed practitioner of the healing arts within their scope of practice under State law."38 CHW QUALIFICATIONS Qualified CHWs include those: » Certified by the RI Certification Board as a CHW » Having a plan for obtaining certification within 18 months RI Certification Board requirements include: > "Completion of six months or 1,000 hours of paid or volunteer experience within the last five years; » Completion of 50 hours of supervised work; » Completion of 70 hours of education; and > Submission of a portfolio, which is a collection of personal and professional activities and achievements." RE|MBURSEMENT / BUDGET According to the SPA, bases of payment for CHW services will be 15-minute units of services for new individual patients, estab- lished individual patients, and groups of two or more." Rates will be increased by the New England Consumer Price Index annually, "Rates are inclusive of travel time and outreach to new CHW patient." Services may be billed for direct contact, face-to-face of telehealth, or collateral services (services delivered on behalf of an enrollee and not directly to or in the enrollee's presence, but the enrollee remains the focus of the service).? Budget impact when submitted: >» FFY 2021: $687,488 > FFY 2022: $2,648,317 Califomia Health Care Foundation www.chcf.org 6 STATUTORY AUTHORITY COVERED SERVICES SOUTH DAKOTA (approved: June 4, 2019; effective: April 1, 2019) Preventive Covered services. Services must meet general coverage services principles including being medically necessary. "CHW services are a preventive service to prevent disease, disability or other 42 CFR health condition, the progression of chronic health conditions 440.130 for individuals with or at risk of a chronic health condition, or for individuals with a documented barrier to care affecting their health.* Identified barriers must be based on a risk assess- ment or prior health care experiences with the person.* CHW services include: » Health system navigation and resource coordination » Health promotion and coaching » Health education and training according to established or recognized health care standards "CHW services must be ordered by a physician, physician assis- tant, nurse practitioner, certified nurse midwife or dentist;" delivered according to a plan of care; and related to a medical intervention.*6 The service must be ordered or referred by the recipient's primary care physician or health home, if applicable." The following also apply:* » Services can be group or individual. » Services must be delivered according to a plan of care. » The plan of care must be written by the ordering provider or by a qualified health care professional supervised by the ordering provider and finalized before rendering of CHW services. Order for plan of care may not exceed one year. >» "CHW services may be provided face-to-face, via telemedi- cine, or via two-way audio only when recipients do not have access to audio/visual telemedicine technology." » Up to five units of individual services may be performed in a clinic setting per year, after which services must be performed in a home and community setting. » A CHW may attend a medical appointment with the recipient. » "Group services may take place in a meeting room of a medical setting." Groups may not be larger than eight people. Noncovered services. Key noncovered services include helping to enroll in government programs, case management, and chore services, and may not be billed to Medicaid." CHW QUALIFICATIONS "Effective January 1, 2023: CHWs must be certified by the CHW Collaborative of SD."* Before January 1, 2023, CHWs must either be certified by the CHW Collaborative of SD or have completed an approved training. CHWs must complete a minimum of six hours of annual continuing education.* CHWs must be employed and supervised by a CHW agency enrolled with SD Medicaid. RE|MBURSEMENT / BUDGET SD will reimburse CHW agencies for CHWs to perform the follow- ing services using the identified CPT codes: >» 98960 (self-management education and training, 1 patient, 30 minutes) > 98961 (self-management education and training, 2-4 patients, 30 minutes) > 98962 (self-management education and training, 5-8 patients, 30 minutes) In addition, the following applies to reimbursement:"" » "Service is only billable if at least 16 minutes of service are provided." » No more than 4 units are billable on a single date of service. » Per-recipient limit is 104 units per year. >» "CHW agencies must be at the provider's usual and customary rate," but services will be reimbursed at the lesser of the provider's rate or CHW fee schedule. Budget impact when submitted: > FFY 2019: $257,200.62 > FFY 2020: $514,427.43 Summary of Medicaid State Plan Amendments for Community Health Workers www.chcf.org 7 STATUTORY AUTHORITY COVERED SERVICES CHW QUALIFICATIONS REIMBURSEMENT / BUDGET SOUTH DAKOTA, conTINUED Documentation. > Type of service performed and whether it was group vs. individual > Summary of services including objectives in care plan the service is related to Recipient receiving services Number of group members, if applicable > > > Date, location, and beginning and end time of service > "Name of individual providing the service" > "CHW signature."°° Provider enrollment /requirements. "CHW agency is required to be enrolled with SD Medicaid to be reimbursed for CHW services." "SD Medicaid does not enroll individual CHWs."*! > CHWs must be employed and supervised by an enrolled CHW agency. > CHW agencies must complete a supplemental provider agreement addendum and submit their written policies and procedures, which must include: » Process to certify the trainee completed the appropriate training v Monitoring of six hours annually of training thereafter v Staff orientation (before entering a client's home unsuper- vised) and annual training v Fingerprint-based background check v Regular checks of the Office of Inspector General's List of Excluded Individuals/Entities and the General Services Administration's System for Award Management lists for excluded people Califomia Health Care Foundation www.chcf.org 8 About the Author Erika Saleski, MPP provides consulting services to state and local governments, and organizations focused on improving health outcomes in low- income communities. Erika is an accomplished public policy professional with more than 15-years of experience in federal, state and local healthcare policy. Erika offers expertise and a proven track record in project management, Medicaid managed care contracting, public policy research and analy- sis, and federal policy negotiation. About the Foundation The California Health Care Foundation is dedi- cated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient- centered health care system. Endnotes . State Plan Amendment 22-0001 (PDA, California Dept. of Health Care Services (DHCS), July 26, 2022. 2. SPA 22-0001, DHCS. 3. DHCS. 4, DHCS. 5. DHCS. 6. DHCS. 7 8 9. 0. 1 = . DHCS. . DHCS. . DHCS. . DHCS. . State Plan Amendment 18-005 (PDF), Family Social Services Administration (FSSA), November 28, 2018. 12. SPA 18-005, FSSA. 13. "IHCP Adds Coverage of Community Health Worker Services" (PDF), HCP Bulletin, May 31, 2018. 14, "IHCP Adds Coverage," HCP Bulletin. 15. JHCP Bulletin. 16. IHCP Bulletin. 17. State Plan Amendment 22-0003 (PDA, Louisiana Dept. of Health (DOH), May 23, 2022. 18. SPA 22-0003, DOH. 19, DOH. 20. DOH. 21. DOH. 22. DOH. 23. Due to the inability to locate the original state plan amendment that integrated CHWs into the Minnesota Medicaid program, all information related to Minnesota's Medicaid reimbursement for CHW services was obtained on the following Minnesota websites: "Provider Manual: Community Health Worker (CHW)," Minnesota Dept. of Human Services (DHS), last modified July 29, 2020; and "Emerging Health Professions: Community Health Worker (CHW)," DHS, last modified July 29, 2020. 24. "Emerging Health Professions," DHS. 25, "Provider Manual," DHS. 26. DHS. 27. DHS. 28. DHS. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. M1. 42. 43. 44, 45. 46. 47. 48. 49. 50. 51, 52. 53. 54. 55. 56. 57. DHS. DHS. State Plan Amendment 12-007 (PDF), Oregon Health Authority, September 20, 2022. Medicaid Coverage of Community Health Worker Services (PDF), Medicaid and CHIP Payment and Access Commission, April 2022. State Plan Amendment 17-0006 (PDF), Oregon Health Authority, July 19, 2017. "Traditional Health Worker Training Requirements for Certification," Oregon Health Authority. Oregon Medicaid Fee-for-Service Reimbursement for Community Health Workers (PDF), Oregon Health Authority, last updated September 1, 2020. State Plan Amendment 21-0012 (PDF), Rhode Island Executive Office of Health and Human Services (EOHHS), May 23, 2022. SPA 21-0012, EOQHHS. EOHHS. EOHHS. EOHHS. EOHHS. EOHHS. State Plan Amendment 19-005 (PDF), South Dakota Dept. of Social Services (DSS), June 4, 2019. Community Health Worker Services (PDP, DSS, last modified June 2022. SPA 19-005, DSS. SPA 19-005, DSS; Community Health Worker Services, DSS. SPA 19-005, DSS; Community Health Worker Services, DSS. SPA 19-005, DSS; Community Health Worker Services, DSS. SPA 19-005, DSS. Community Health Worker Services, DSS. Dss. DSS. DSS. DSS. SPA 19-005, DSS. DSS. Community Health Worker Services, DSS. Summary of Medicaid State Plan Amendments for Community Health Workers www.chef.org 9