INTRODUCTION

Community health workers (CHWs) are an evidence-based model to enhance care coordination, support care of patients with chronic conditions, and improve diabetes-related outcomes (e.g., glycemic control).1–6 Integrated medical and social care via CHW services is a growing area of interest, particularly among health care organizations that care for underserved populations. In integrated medical and social care, the CHW role can include delivering services that address the medical needs of individuals with simultaneous efforts to address unmet social needs that present barriers to health. For example, for a client with diabetes who reports food insecurity, the CHW may provide self-management skill building support and tailored diabetes education in the home. The CHW may also connect the client to a range of community-based resources (e.g., support enrollment in Supplemental Nutrition Assistance Program (SNAP), offer navigation to farmers’ markets that offer SNAP-Ed for food demos, nutrition classes, and locations that match SNAP dollars for twice the amount of produce). Many organizations that integrate CHW services are also seeking opportunities to describe the business case for CHW services (e.g., analysis of preventable ED/inpatient utilization, piloting shared risk/return framework for payors and providers) and long-term financial strategies to sustain the CHW role in integrated medical and social care.

Medicaid reimbursement for CHW services (e.g., self-management education, targeted case management services, home visits, health promotion activities) provides access to CHW support for underserved populations (e.g., beneficiaries with two chronic conditions, beneficiaries receiving targeted case management services, beneficiaries with complex behavioral or physical health needs). Currently, Minnesota is one of 21 states that authorize Medicaid payment for CHW services and one of seven states to allow CHWs to provide services under the state plan.7 However, in practice, obtaining reimbursement for CHW services has been challenging. Barriers include the following: (1) lack of clarity around Medicaid reimbursement policies and procedures; (2) electronic billing system barriers and complexities; (3) Medicaid fee schedule reimbursement rates that are insufficient to cover the costs of delivering CHW services; and (4) factors such as the expertise and capacity of organizations to navigate administrative hurdles.8

CHW Solutions is a CHW service and technical assistance provider based in St. Paul, MN, that provides direct services through a dedicated CHW team. Additionally, CHW Solutions provides clinical oversight of CHW activities and billing support for organizations lacking internal expertise with billing for CHW services. CHW Solutions’ team delivers integrated medical and social care via a CHW Medicaid billing model by combining health education, self-management skill building and community resource connection into each CHW visit. CHWs ensure patients are connected to their local care team, including primary care and managed care organization (MCO)–based coordinators, regardless of health system affiliation.

We provide an overview of the barriers and strategies to operationalize Medicaid reimbursement for CHW services based on lessons learned in Minnesota. We recommend how other states, payers, and organizations can more effectively operationalize Medicaid payment for CHW services.

Legislative Context

In 2005, Minnesota became the first state to implement a standardized CHW curriculum.8 In 2007, the Minnesota Legislature approved fee-for-service (FFS) Medicaid reimbursement for CHWs delivering health education and care coordination services.8 The provisions of the bill (HF 1078) are codified under several statutes, and HF 1078, Subdivision 49, is summarized in Figure 1.9–11 In 2013, the Centers for Medicare and Medicaid Services (CMS) clarified regulations authorizing preventive services provided by CHWs and issued guidance that State Plan Amendments (SPAs) would be required to receive approval for Medicaid to cover the proposed services.12 States may develop SPAs with CMS to modify how Medicaid programs are run in order to provide different services, including expanded authority for CHWs to provide services.13 In 2013 a SPA was approved in Minnesota and effective in 2015 and allowed for reimbursement of CHW services, only for health education services.14

Figure 1
figure 1

Community Health Worker Excerpt of Bill HF 1078, Subdivision 49. Citation: 2021 Minnesota Statutes. 256B.0625 COVERED SERVICES. https://www.revisor.mn.gov/statutes/cite/256B.0625. Published 2021. Accessed March 25, 2022.

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The requirements for CHW MN Medicaid reimbursement are published in the Minnesota Health Care Programs (MHCP) CHW Provider Manual and are summarized in Figure 2.15 In Minnesota, critical requirements include the following: CHWs must complete a qualified certificate program, a clinician must order and provide general oversight of the services, and service documentation must follow Medicaid standards.

Figure 2
figure 2

Summary of Minnesota health care programs community health worker reimbursement requirements. Abbreviations: CHW, community health worker; APRN, Advanced Practice Registered Nurse; CPT, current procedural terminology. Adapted from the Minnesota Department of Health. Minnesota Health Care Programs Community Health Worker Provider Manual. https://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_140357.Published July 2020. Accessed March 28, 2022.

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BARRIERS AND STRATEGIES TO LEVERAGE AVAILABLE MEDICAID REIMBURSEMENT FOR CHW SERVICES IN MINNESOTA

Although Medicaid reimbursement was approved in Minnesota in 2007, many organizations struggled to operationalize and access reimbursement for CHW services. Starting in 2017, CHW Solutions encountered barriers and established strategies for delivering CHW services, seeking reimbursement, and providing technical assistance to organizations working with CHWs. CHW Solutions focused on developing sufficient organizational capacity, clarifying regulation, navigating billing processes, securing adequate financing, engaging with payers, and enhancing bi-directional communication and care coordination (Table 1).

Table 1 Barriers and Strategies to Leveraging Available Medicaid Reimbursement for CHW Services in Minnesota
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Organizational Capacity

A single organization often lacks the expertise and administrative capacity required to both obtain reimbursement for CHW services and advocate for sustainable financing models. CHW Solutions built a team prepared to navigate policies and systems, build relationships with key external stakeholders (e.g., DHS, payers), provide clinical oversight of CHWs, and develop expertise in medical billing.

Regulation

When regulatory language lacks clarity, organizations struggle to translate regulations into direct CHW service delivery, submitting claims, and successfully receiving payment. Figure 2 summarizes reimbursement requirements from the MHCP CHW Provider Manual, for example: “The service must involve teaching the patient how to self-manage their health (including oral health) in conjunction with the health care team.” Organizations are left to interpret what constitutes teaching how to self-manage (e.g., individual patient education, skill building, navigation to resources) and how to work in conjunction with a health care team (e.g., clinic co-location, remote consultation with teams while serving patients in community settings). CHW Solutions developed and then articulated to the Department of Human Services (DHS) a model of CHW patient education that includes the following: health education, self-management skill building, and community/resource connections. The legislature gives authority to State agencies to develop administrative rules. Therefore, DHS has the capacity to modify rules based on their priorities and interests, thus shaping how CHW services are structured, delivered, and sustained (e.g., to bill for CHW services for groups larger than 8 DHS added a U9 modifier to CPT code 98962).

Billing

The basic steps of billing for CHW services initially proved to be complicated, burdensome, and unsuccessful. Billing requires specific steps including confirming eligible CHW services for reimbursement; navigating how rendering, ordering, and billing providers are referenced on claims; and identifying how billing may vary based on location of CHW (e.g., community-based organization or federally qualified health center (FQHC)). CHW Solutions iteratively discussed the structure of CHW activities and reimbursement with DHS to clarify and modify implementation and payment for CHW services. This process yielded strategies to clarify acceptable services (e.g., preventive education, education for patients with diabetes diagnosis), confirm specific diagnosis and provider codes for claims, improve efficiency of dual-eligible beneficiary claims processing, and document CHW services in compliance with DHS rules (e.g., patient education plan, date of service). After confirming a CHW service model aligned with established regulations and rules, it was possible to submit claims to Medicaid for services provided, troubleshoot denied claims, and clarify the necessary content for future claims.

Government Financing

The average cost to deliver one unit of CHW services exceeds the current Medicaid fee schedule for CHWs.8 The current reimbursement rate for one-on-one CHW health education services (CPT code 98960) in Minnesota is $20.99 per 30-min unit. Even once higher reimbursement rates are negotiated with managed care organizations, CHW service providers must deliver patient education activities at 80% FTE in order to break even under the current rates and benefit scope for CHW services. For example, the cost for a 30-min unit of CHW services can range from $60 to $100 and varies depending on the context of service delivery (e.g., travel time and associated costs, outreach, care coordination, phone calls data tracking needs, etc.). Organizations need to advocate to increase rates of Medicaid reimbursement for CHW services. CHW Solutions directs external funding sources (e.g., grants) to underfunded CHW activities until reimbursement rates are sufficient to cover full cost of services.

Payer Financing

CHW Solutions engages payers in pilot projects to demonstrate proof of concept for CHW services, and CHW service value to MCOs and their members. Grant-funded initiatives provide a setting to engage CHW provider organizations, payers, and public health organizations to address strategies to improve outcomes for shared populations. In this context, payers identify ways to implement CHW services with their members, including patients referred from FQHCs (e.g., closing care gaps, connecting members to community-based programs, addressing social determinants of health). Pilot projects demonstrate the value of CHW services, and provide a foundation for renegotiating MCO rates for CHW services.

Cross-sector Collaboration

One sector or organization alone cannot address all barriers to financing, billing, and sustainability of CHW services. Cross-sector collaboration (i.e., collaboration that can occur across social services, community development and other community-based organizations, health care organizations, government agencies, and/or payors) yields opportunities to solve problems and identify new strategies. Organizations that care for underserved patients and those without insurance, like FQHCs, would like to have options to connect patients to CHWs. Cross-sector collaboration can facilitate access to resources and more varied funding sources that may not be accessible to organizations working in isolation. For example, in 2018, partnership across a local public health department, CHW Solutions, and FQHCs created an ideal setting in Minneapolis to test CHW service implementation options, deliver CHW services, and pursue reimbursement over 4 years.16 Bridging the Gap: Reducing Disparities in Diabetes Care, a Merck Foundation–supported initiative, blended expertise, administrative capacity, and organizational missions across three sectors, and piloted opportunities to link FQHC patients (including uninsured patients) with CHW services via diabetes care transformation.16 In this initiative, philanthropic grant funding supported CHW services for uninsured patients. Additionally, grant funding helped fill the gap between the cost of implementing CHW services and the current reimbursement rate for CHW services in the FQHC context, a new setting to test CHW service delivery and payment strategies with an external CHW provider organization.

Bi-directional Communication and Coordination

Access to patient-level data improves CHW workflows, outreach, patient engagement, and service efficacy. Leveraging technology and other communication strategies can enhance outreach to patients and tailor CHW services to specific settings. The Minneapolis Health Department supported FQHCs to pilot the use of a bi-directional electronic social needs screening and referral platform, NowPow, to link patients with community-based organizations, including CHW Solutions. The platform presented pros (e.g., secure messaging, organization of referrals for shared populations) and cons (e.g., separate platform for FHQC staff to navigate, the relative administrative capacity of organizations to handle referrals and communication through additional electronic platforms). In the absence of ideal technology strategies, effective tools to coordinate and communicate with organizations can include the following: secure fax, secure email, regular meetings, standard forms, and tailoring referral processes and communication methods to the needs or preferences of individual organizations (e.g., sharing referrals via secure fax, communicating via weekly huddle, supporting electronic referrals and real-time communication and access to data by creating secure remote user electronic medical record access for external CHW).

LEVERAGING AVAILABLE MEDICAID REIMBURSEMENT FOR CHW SERVICES: RECOMMENDATIONS FOR OTHER ORGANIZATIONS, PAYERS, AND STATES

Establishing Medicaid reimbursement for CHW services is only one step to improve access to CHW services. To leverage available Medicaid reimbursement, organizations, payers, and states need to bridge the gaps between interpreting regulations, translating them to direct service delivery, submitting claims, and successfully receiving payment for CHW services (Table 2).

Table 2. Recommendations for Other States and Health Care Organizations Seeking Options to Deliver and Receive Payment for Community Health Worker (CHW) Services
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Organizations should prepare to encounter and work through barriers and strategies at multiple levels, and chart a multi-year path to navigate regulatory, financing, billing, and sustainability issues. Observing Minnesota’s experience with a narrow scope of services (e.g., patient education) for reimbursement, South Dakota intentionally designated a broader scope of services to be paid by Medicaid (e.g., Health System Navigation and Resource Coordination, Health Promotion and Coaching, Health Education).17 As others navigate practical steps to implement CHW services, they should begin by connecting with contacts at state agencies (e.g., DHS) to offer specific examples of service provision and billing scenarios to assess compliance with state guidelines. This is a necessary part of the process and will support efforts to deliver CHW services and receive payment.

Organizations should be prepared to troubleshoot errors with claims upfront. For example, submit a few claims to work through all the details before submitting large batches of claims. A medical director role provides infrastructure for CHW activities and helps articulate value of CHW services. Regarding government and payer financing, CHW provider organizations and MCOs should plan to build relationships over time; this will support navigating reimbursement steps long-term. Communicate the value of the CHW role and request/supply rates that are sufficient to sustain CHW services.

CONCLUSION AND FUTURE DIRECTIONS

FFS Medicaid payments for CHW services can provide sustainable funding to reach Medicaid recipients with CHW services. The Minnesota experience of navigating reimbursement echoes some challenges in Oregon, where coordinated care organizations (CCOs, similar to accountable care organizations) also report barriers with FFS payments (e.g., state guidance on CHW billing policy, acceptable billing codes).18 Strategies to address these problems should include technical assistance for organizations to navigate implementation of CHW services, billing structures, and reimbursement processes. Although Medicaid FFS payment for CHW services provides options for reimbursement, the process is cumbersome and confusing, hindering uptake of CHW services, and Medicaid funds do not cover services delivered to uninsured patients. Continuing to identify and eliminate the problems that accompany CHW reimbursement through FFS payment will ease the burdens on CHW service providers.

Ultimately payments outside of FFS payment (e.g., global budgets, capitated payments) may be critical for supporting care transformation that delivers proactive care for patients with complex needs.18 However, for many organizations, payment outside of FFS payment is not accessible or attainable at this time. Professionals in community and public health sectors have the content and implementation expertise to deliver CHW services, and FFS payments for CHW services can be a pragmatic first step under available reimbursement options to pilot and deliver services to address medical and social needs. Regardless of the approach, payment levels must be sufficient to cover the full costs of delivering CHW services.

CHW service delivery and financing mechanisms are an integral part of the larger effort to build robust models of integrated medical and social care. CHWs represent an available intervention, and CHWs have demonstrated their value in health care and community settings. Leveraging all available CHW payment interventions will sustain services and advance health equity.