Info on Changes to CHW Reimbursement by Medicaid

With input from its Advisory Council, CHWARI has compilied this brief explanation of both the history of the RI CHW Medicaid Benefit as well as its status as of November 2025.

Summary of the RI Medicaid CHW Benefit’s History

CHW definition quoted from the Rhode Island Department of Health (RIDOH) website: 

“Community Health Workers (CHWs) are frontline, public health professionals who often have similar cultural knowledge, practices, and beliefs, chronic health conditions, disabilities, or life experiences as other people in the same community.  CHWs are also known by other professions and job titles (e.g. … promotores de salud, coaches, lay health advisors, peer navigators,  etc.) and many CHWs may be cross-trained and hold multiple certifications and disciplines in other areas of healthcare, mental health, and behavioral health.” 

Nationwide, studies have revealed a significant return on investment and improvement in health outcomes when CHWs provide services. In 2022, after years of advocacy by many organizations including RIDOH, a CHW benefit was included in the RI State Medicaid Plan. This was a huge win for CHWs and for Rhode Island’s most vulnerable and under-served populations. Including a CHW Medicaid Benefit has been cited as a way for states to make their CHW workforce sustainable. We are grateful to the engaged allies who worked in partnership with CHWs for decades to remove barriers to care for individuals and families. Aligned with RI’s Health Equity Zones (HEZ), Rhode Island is widely recognized as a national model for CHW integration.

The original RI Medicaid CHW benefit allowed for a very broad scope of practice that appeared to reflect the essence of CHW practices and allowed for meeting client needs in authentic ways. As referenced in the above award-winning CHW logo created by RIDOH, CHWs could support clients by being ‘a bridge to better health,’ by connecting them to services, accompanying them to appointments, addressing food access and helping apply for benefits. There was no set daily limit for CHW services, allowing CHWs to navigate families from crisis to safety in real-time.  They could bill Medicaid independently or as part of a larger organization for 18 months while they worked toward certification, allowing them to be paid for their time as they earned the necessary 1000 hours required for certification, rather than volunteer. As it has become standard of care to screen for health-related social needs, Medicaid provided a pathway for CHWs to be reimbursed for the work they do in addressing these needs with “Z-Codes” that allowed individuals to self-identify as having unmet health-related social needs. RIDOH provided a “Standing Order” to assist smaller organizations in streamlining the referral process.  These flexible regulations allowed CHWs to provide immediate help to their community (link to CTC RI Article), though the absence of early oversight and quality control mechanisms failed to respond to client vulnerabilities.  During this time, Rhode Island was cited multiple times at the national level as a positive example of an effective and thriving CHW workforce. (NEJM, APHA, )

The Rhode Island CHW workforce grew significantly, especially as many CHWs began operating and billing Medicaid independently. This direct reimbursement allowed them to address the needs of their community authentically, immediately, and in their own language. Building on their own lived-experience, community connections, cultural competence, and professional expertise, they “met people where they were at” and established relationships that provided pathways to care for our most vulnerable residents. The majority of these new small businesses were owned by BIPOC (Black, Indigenous, and People of Color) CHWs with lived experience related to Social Determinant of Health (SDOH) challenges.

It is unclear how the standards were monitored in the initial year of implementation to assess the efficacy of billing or to troubleshoot areas of concern proactively. In early 2025 significant billing fraud was detected within a small subset of the broader CHW workforce.  Meanwhile, the majority of CHWs and organizations billing Medicaid for CHW services worked in good faith to adhere to all defined regulations while serving Rhode Islander’s with integrity, passion, cultural sensitivity and humility. While any fraud is unacceptable, these incidents represent a minority of claims and should not overshadow the integrity and impact of the broader CHW workforce.

After three years of implementation and the detection of fraud beginning in the third year of the project, one cannot help but question if a more proactive and timely assessment of practices could have helped to avoid the current situation of fraud and negative attributions to the CHW workforce.  It is heartbreaking to think of the hard work and collaboration that went into gaining approval for Medicaid billing for CHWs only to have it culminate in the current state of affairs that will surely decimate a critical workforce and reduce the availability of supports and services for the vulnerable populations CHWs serve. 

In May of 2025, significant reductive changes were announced to the RI CHW Medicaid Benefit. For example, a daily limit of two hours was set for reimbursable services. CHWs argued that two hours is not nearly enough time to complete un-interruptible tasks like the intake of an unhoused family in crisis. “Collateral services” such as assistance applying for benefits were eliminated. Z-Codes and Standing Orders were eliminated.  CHWs and allies advocated thoughtfully for revisions to the changes, in vain. Many independent CHW businesses closed as a result. Multiple established agencies and medical practices either paused billing Medicaid for CHW services, or eliminated their CHW workforce. These sweeping restrictions dramatically reduce service flexibility and reimbursement capacity – changes that punish compliant CHWs, organizations, and clients alike.

In September of 2025, the EOHHS released a revised Fiscal Year 2027 Restrictive Budget that threatens to cut the RI CHW Medicaid Benefit entirely. What happens next remains to be seen.

The challenges faced by the CHW Medicaid benefit stem not from a lack of community integrity, but from a lack of sustained administrative partnership. Strengthening this partnership through oversight, guidance, and evaluation can help rebuild trust and ensure that RI’s investment in CHWs achieves its full potential. In the current climate of myriad challenges to community health, we need this critical workforce more than ever.

-The Community Health Worker Association of Rhode Island

10/29/25