Principles for CHW Reimbursement Rates 

Developing Sufficient Rates. As of January 2024, there was significant variation in Medicaid payment rates for CHW/P/CHR services covered by state fee-for-service (FFS) programs, ranging from just under $10 to $35 per 30 minutes.¹⁸ For comparison, the average national rate for 30 minutes of Medicare Community Health Integration services provided by a CHW is $50.26.¹⁹

States with SPAs authorizing CHW/P/CHR reimbursement have largely established FFS payment rates. Some states have included requirements for integration of CHW/P/CHR services into managed care contracts. 

An analysis of state Medicaid FFS and managed care reimbursement for CHW/P/CHR services found that payment rates need to be higher to support the financial viability of CHW/P/CHR programs. The study recommended a minimum FFS rate of $53.24.²⁰

Regardless of how CHW/P/CHR services are paid (e.g., FFS or MCO), the following principles should guide rate development. Rates must: 

• Ensure delivery of high-quality services (e.g., in-person services provided at least once a month)
• Support access to services (e.g., payments that cover both direct and indirect costs, enabling sustainable operation of a CHW/P/CHR program)
• Ensure livable wages for CHW/P/CHRs and promote opportunities for CHW/P/CHR career advancement

Considerations for federally qualified health centers (FQHCs). FQHCs are a large employer of CHW/P/CHRs in many states and a critical access point for many Medicaid beneficiaries. As states develop CHW/P/CHR reimbursement rates, CHW/P/CHR services provided by FQHCs must be accounted for either in the state’s FQHC prospective payment system (PPS), through billing codes outside of the PPS rate, or through an alternative approach (e.g., an alternative payment model). 

Notes

1. UN Enable. International Day of Disabled Persons, 2004. https://www.un.org/esa/socdev/enable/iddp2004.htm. Accessed November 10, 2024.
2. Gyurina C, Victoriano L. Environmental scan on community health workers: a fifty-state scan of Medicaid reimbursement approaches for the CHW workforce. Connecticut Health Foundation. https://www.cthealth.org/wp-content/uploads/2024/01/CHW-Medicaid-Policies-and-Reimbursement-Approaches-by-State.pdf. Published January 2024. Accessed November 10, 2024.
3. National average physician fee schedule payment level for HCPCS code G0022. CMS. License for use of current procedural terminology, fourth edition (“CPT®”). https://www.cms.gov/medicare/physician-fee-schedule/search Y=0&T=4&HT=0&CT=2&H1=G0022&C=1&M=5. Accessed September 25, 2024. 
4. Basu S, Patel SY, Robinson K, et al. Financing thresholds for sustainability of community health worker programs for patients receiving Medicaid across the United States. J Community Health 2024;49:606–634. https://doi.org/10.1007/s10900-023-01290-w.