Community Health Workers and Medicaid Reimbursement

Background

Community health workers (CHW) are an important part of the public health system. CHWs are deeply rooted in the communities they serve, and therefore possess firsthand knowledge of a local community’s culture and needs. They work in diverse roles, including and not limited to care coordinators, community health educators, outreach and enrollment agents, patient navigators, and peer educators. Given their expert knowledge into culturally appropriate health promotion, CHWs assist with accessing both medical and non-medical services, translation, patient advocacy, home visits, and social support. 

Research shows that CHW interventions effectively reduce health disparities and promote health equity, especially in communities of color where individualized, cultural knowledge is required to provide effective access to services. For every dollar that is invested into CHW interventions, an estimated $2.47 is saved. For example, CHW visits have also been shown to help Medicaid recipients, as made evident when a CHW asthma home visiting intervention improved trigger management, clinical outcomes, and Medicaid cost savings. 

Historically, CHW programs have been run and funded by community health centers and other community-based organizations. However, these organizations often run on lean budgets, which limits ways to hire or use CHWs. This often manifests in CHWs working with a large number of clients or for lower wages—factors that drive high turnover rates and correlate with increased resignations, as evident by a higher CHW turnover and resignation rate of 25%. Without a consistent workforce, the loss of both institutional and community knowledge threatens the continuity of care for vulnerable populations. 

Medicaid reimbursements may be a lifeline for CHWs that provides much-needed financial support and recognition for CHWs. Under current guidelines, Medicaid plans to reimburse for certain CHW services (such as care coordination and diagnosis-related patient services) as determined by the state Department of Healthcare and Family Services (HFS) and approved by the federal Centers for Medicare and Medicaid Services (CMS). With over 3.4 million Illinois residents being enrolled in Medicaid as of April 2024, ensuring that CHWs receive proper reimbursement is key to sustaining quality care across the state. 

However, state governments have determined that until certification is in place, billing cannot happen for Medicaid. This requirement led to 15 states creating Medicaid plans that fund CHWs, and Illinois is not far behind. In 2021, the Illinois legislature passed HB0158 to establish a certification program for CHWs. This legislation directs both the Illinois Department of Public Health (IDPH) and HFS to develop the necessary infrastructure to support CHW certification and reimbursement.

Ongoing Certification Process Work

The implementation of the legislation currently involves two processes. First, HFS is developing a list of services for which CHWs will be eligible for Medicaid reimbursement, subject to fiscal appropriation and approval from CMS. The Act also directs HFS to amend its contracts with managed care entities to allow them to employ CHWs or subcontract with community based organizations (CBOs) that employ CHWs. Simultaneously, IDPH is creating the CHW certification process and a CHW registry. They are working with associations and other leaders active in the CHW workforce development landscape to create administrative rules—such as determining the number of practical experience hours required, or educational and potential age requirements for courses. 

Implications and Drawbacks

But despite the promise of increased funding, this situation is a bit more complicated. To receive reimbursements, CHWs must be certified and put through a more stringent system as they work, potentially changing their historically flexible, community-based role. The bill also requires CHWs to work under the supervision of an “enrolled medical program provider,” which raises questions about the ideal supervisory structure. What kind of medical professionals do we want to be classified as a supervisor, and what are the implications of having too high or too low of professional levels as supervisors? Moving closer to the conventional healthcare system may end up distancing CHWs from their historical model of community-centered care, which is a shift that might undermine the very advantage of community knowledge they bring to their work. Furthermore, CHWs are not required to be certified for employment, as noncertified CHWs can still be employed through funding sources outside of Medicaid. Future data about CHW contributions may be incomplete if noncertified CHWs are not adequately represented.

What Can We Do

During this transition, public engagement is critical to shaping the future of CHW work and Medicaid reimbursements. IDPH is currently holding quarterly meetings to discuss the CHW certification process, which provides an important opportunity for policy stakeholders to share their input. By joining and sharing your experiences and insights, we can better shape how CHW work and Medicaid reimbursements will work. 

Additionally, because IDPH is limited to gathering data on certified CHWs, a comprehensive registry that includes both certified and noncertified CHWs would help capture the full scope of their work. This would ensure that policy decisions are informed by accurate and complete data.  

Furthermore, the aging network can make more deliberate choices to try and bring on CHWs into their workforce to improve their programs. AmeriCorps Seniors and other programs are workforce resources that can validate the need for Medicaid reimbursement and enhance care for older adults. 

— by Louis Lee, Northwestern University Student Intern