The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
January 17, 2025
Fact Sheet
Sofia Espinosa
Mary Louise Gilburg
Publication
Dec 10, 2024
Dec 2, 2024
Nov 25, 2024
Back to Publications
Community health workers, promotores, and community health representatives (CHW/P/CHR) address health-related social needs through resource navigation, peer social support, health coaching, and advocacy. As Gustavo Zuniga, a community health worker at Mental Health Cooperative in Nashville, Tennessee, explained as he opened this MLSN briefing on Medicaid reimbursement, he used flexible person-centered care and goal-making strategies to work with his client, Gary, to address health-related social needs by connecting him to housing, substance use treatment, and appropriate emergency services.
“I meet people where they are, and let the care be driven by them. I get to walk alongside them. It is preventive care that that goes beyond the clinic and into the heart of the individual.” — Gustavo Zuniga, Community Health Worker, Mental Health Collaborative
According to Janée Tyus and Shreya Kangovi of IMPaCT Care, CHW/P/CHR programs have historically relied on a patchwork of grants for funding, but many state Medicaid programs are now implementing some form of CHW/P/CHR coverage and payment policy. To help more states create evidence-informed policies, IMPaCT Care developed a toolkit published by the Milbank Memorial Fund.
The Medicaid Reimbursement for Community Health Worker Services: Model State Plan Amendment & Other Guidance Toolkit provides:
“The goal of this toolkit is to enable policymakers to translate Gustavo’s magical story into routine care in your states by creating sustainable funding for community health worker services.” — Shreya Kangovi, MD, MSHP, Chief Executive Officer, IMPaCT Care
Representatives from New Mexico and South Dakota, two states that have implemented payment policy for CHW/P/CHR, described the scope of services being paid their state reimbursement strategies. Both states relied on significant input from CHW/P/CHRs in their state, as well as community-based organizations (CBOs) and provider organizations, to inform key policy decisions during their design and implementation process.
In New Mexico, challenges to reimbursement have included onboarding CHWs/CHW organizations as Medicaid providers, helping them to navigate billing processes, and distinguishing the CHW profession from others that may conduct similar activities like care coordination, which are reimbursed through Medicaid MCOs’ administrative funding and Medicaid reimbursable services. Alanna Danica of New Mexico Medicaid called out partnership with the Department of Health’s Office of Community Health Workers, which certifies CHWs, as valuable in implementation.
Reimbursement was established via a state plan amendment under the preventative service section to reach people in and outside of Medicaid MCOs.
“Most of our 1115 waiver programs are implemented through capitation with our managed care organizations. We wanted to make sure that people who were in fee for service, and who were Native American served by community health representatives, were able to use this benefit, so the state plan amendment was the better way to go to offer direct reimbursement across all MCOs.” — Alanna Dancis, DNP, Chief Medical Officer, New Mexico Medicaid
South Dakota prioritized sustainability and considered return on investment to calculate reimbursement rates. South Dakota also emphasized the importance of data to identify the health needs and the impact of CHWs at the county level and coordinate with other agencies to meet social needs.
“We can actually pull up a map of South Dakota by county…and we can see exactly which counties are being impacted by [housing and food insecurity] based on the diagnoses codes that are being billed to us…which helps us inform decision making for other agencies, such as the Department of Health and Maternal Child Health agencies.” — Ashley Lauing, MPH, Policy Strategy Manager, Division of Medical Services, South Dakota Department of Social Services
South Dakota has shared their operational insights by providing technical assistance to over 20 states.
Panelists had a productive dialogue on the risks and benefits of program-level accreditation versus individual CHW certification.
“CHW program accreditation requires that the quality onus is on the program, and it gives CHWs what they need beyond training and certification. It makes sure CHWs have guardrails in place at work, that they’ve got authentic CHWs, fair compensation, a career ladder and the support that they need, [like a] cap of caseloads, so they’re not working too hard with too many people. We can’t just focus on CHW training and certification as a stamp of quality. We need to go a little bit deeper to protect that workforce.” — Janée Tyus, MPH, Head of Community Mobilization, IMPaCT Care
The briefing highlighted the critical importance of Medicaid reimbursement in supporting CHW/P/CHRs, with state examples and the IMPaCT Care toolkit offering actionable models for implementation. States can use this adaptable toolkit to craft evidence-informed state plan amendments that are tailored to their specifications, including standing orders, billing requirements, and inclusion of community-based organizations to advance sustainable CHW services.
