Medicaid Reimbursement for CHW Services, Explained
The Rhode Island Executive Office of Health and Human Services (EOHHS) has been enabled by a recent State Plan Amendment to reimburse for community health worker services. The landing page is here with links to the Provider Manual. Here are some highlights!
Which community health workers can participate?
- Those who are certified by the RI Certification Board (ricertboard.org)
- OR… Those who have a plan for working toward RICB certification, to be achieved within 18 months.
Which Medicaid beneficiaries can get these services?
The requirements seek to cover anyone who needs them. Examples include:
- Person has diagnosis of one or more chronic health (including behavioral health) conditions
- Person has had two or more missed medical appointments
- Results of the person’s social determinant of health screening indicating unmet health-related social needs
- Person expressed need for support in health system navigation or resource coordination services
How can providers get reimbursed?
- All prospective CHW providers must enroll with Medicaid as CHW providers. This includes those already enrolled as another provider type.
- Agencies/employers can enroll as CHW providers and bill for their workers’ services. CHWs can also enroll independently if not part of an agency.
- Enrollment is completed using the RI Medicaid Healthcare Portal (HCP). To access the RI Medicaid Portal, use the following link: https://www.riproviderportal.org.
- Step-by-step enrollment instruction can be found on the portal home page. The Healthcare Portal Resource Page can be accessed here: http://www.eohhs.ri.gov/ProvidersPartners/HealthcarePortal.aspx.
- Note that CHW services are all billed directly to Medicaid. Even if a person is enrolled in managed care (e.g., with Neighborhood, United, or Tufts), providers should still bill Medicaid directly.
Reimbursement Rates as of 7/1/24
In case you missed them:
On Feb 7th, 2023, we hosted a “Medicaid Enrollment & Billing Review” Webinar. Here are are the slides from that presentation. Here is the link to the zoom recording. We hope that helps!
If you have any questions or run into problems with the enrollment process, please contact Andrea Rohrer, [email protected] for assistance.
See blog National Academy for State Health Policy’s blog on State Plan Amendments for Medicaid CHW financing