Medicaid Coverage Expanded by MDHHS to Include Community Health Worker Services

By: Shea Mace, PA-C, Wachler & Associates, P.C.
1/2/2024

On December 7, 2023, MDHHS announced that community health worker services will now be covered by Medicaid. The new policy is effective January 1, 2024, and chiefly applicable to the Medicaid Fee-for-Service (FFS) program. Medicaid Health Plans (MHPs) and Integrated Care Organizations (ICOs) must also comply by offering the full range of services described within the policy, although they may provide additional services beyond those specified and may develop review and prior authorization criteria different than Medicaid requirements.

CHW Overview

Community health workers (CHWs) are non-licensed but trained public health providers who have distinct knowledge and appreciation of the community they serve. They function as a liaison between community members, healthcare providers, and social services. CHW services must be delivered face-to-face and broadly include assistance with health system navigation, resource coordination, health promotion and education, and the use of screening and assessment tools.

Beneficiary need for CHW services must be recommended by a licensed healthcare provider, including but not limited to a physician, physician assistant, nurse practitioner, registered nurse, licensed master social worker, dentist, or psychologist. Necessity must be assessed and established by using a health risk or social determinant of health (SDOH) screening tool. Conditions that endorse the need for CHW services include chronic health (including behavioral health) conditions, unmet health-related social needs, or pregnancy and post-partum care (up to 12 months).

CHW Covered Services and Requirements

Covered CHW services include assisting beneficiaries with understanding and navigating their coverage plans, facilitating the scheduling of appointments, providing access to relevant community resources, administering education regarding chronic health conditions, offering safety and risk reduction strategies, and promoting preventative services such as immunizations and cancer screenings. Medicaid does not cover CHW services that require a licensed clinician or duplicate services covered under the existing Medicaid state plan. These non-covered items include transportation of beneficiaries, companion services, delivery of medications or medical supplies, personal care such as shopping and cooking meals, respite care, and employment services. However, CHWs may help facilitate referrals to these services.

CHWs must meet specific qualifications in order to be eligible for Medicaid reimbursement. Requirements for CHW qualification include being age 18 or older, possession of a high school diploma or equivalency diploma/certificate, fulfillment of the CHW Training Program Pathway or the Work Experience Pathway, completion of the CHW application with the designated contractor, being listed in good standing on the MI Medicaid CHW registry, and satisfaction of provider enrollment requirements. CHWs also must complete and submit 6 hours of continuing education annually through an MDHHS-approved training program to remain in good standing.

Once a CHW has been verified by the appropriate MDHHS contractor as having met all required qualifications, they must complete the Medicaid provider enrollment process. This involves completing an online CHAMPS application and enrolling as a Rendering/Servicing-Only Provider with an individual (Type 1) NPI. CHWs must also link themselves with at least one billing provider in CHAMPS who possesses either a Type 1 or Type 2 (group/organizational) NPI. CHWs will be held to all germane MDHHS Medicaid Provider Manual policy provisions, inclusive of the General Information for Providers Chapter.

Reimbursement and Billing Considerations

Billing codes to be utilized for CHW services include 98960 (education and training for patient self-management; individual patient), 98961 (education and training for patient self-management; 2-4 patients), and 98962 (education and training for patient self-management; 5-8 patients). To be considered for payment, the codes must be documented in 15-minute increments (equal to one unit of service) and billed with a CG modifier. The size of each group is limited to 8 beneficiaries for billing purposes.

Providers must also document the type of service provided in the notes/comments section of the claim using specific codes depending on whether the beneficiary need is related to a chronic health condition, social need, pregnancy, or other eligibility criteria. The list and description of these codes can be found in MDHHS Bulletin Number MMP 23-74. The CHW must be enrolled in CHAMPS on the reported date of service and a Medicaid group or organization must document the enrolled CHW as the rendering/service provider within the proper claim field.

For beneficiaries enrolled in a MHP or ICO, providers must submit claims for CHW services to the beneficiary’s assigned plan. If the beneficiary is enrolled in FFS, CHW providers must submit claims through CHAMPS. It should be noted that for each beneficiary, CHW services may not exceed 2 hours (8 units) per day and 16 visits per month, totaling a maximum of 32 hours (128 units) per month. Exceptions require prior authorization and may be made for medical necessity in collaboration with the referring licensed provider. CHW services are not subject to Place of Service restrictions.

CHW services provided within Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Tribal Health Centers (THCs), and Tribal FQHCs do not count as qualifying visits. These clinics will be reimbursed for eligible CHW services at the applicable Medicaid fee schedule rates, outside of the Prospective Payment System (PPS) methodology or All-Inclusive Rate methodology. CHWs may also serve as a staff member of a Health Home Care Team (HHCT) or FQHC/Designated Health Home Partner. It should be noted that CHW services may not be billed separately if inclusive in the monthly core services submitted by a Health Home.

MDHHS is hopeful that expansion of coverage for CHW services will help alleviate health disparities, promote preventive care, and improve health outcomes in Michigan. Providers interested in recommending these services to their Medicaid patients should take note of the unique requirements so as to ensure billing compliance.