New Ways to Finance Community Health Worker Services in Medicare: Evidence Roundup

Blog
Logan Kelly, Center for Health Care Strategies
Two community health workers talking and looking at an electronic tablet together.

Community health workers (CHWs), also referred to as community health representatives, promotores, and peer navigators, bridge health and social care by performing roles such as care coordination, care transitions support, and connection to social services. CHWs often share life experiences with the communities they serve, which helps them to understand and help to address health-related social needs.

This blog post is part of a Better Care Playbook Evidence Roundup series that links critical evidence and implementation resources with emerging state and federal policies to help inform and accelerate implementation strategies to improve health and health-related services for people with complex health and social needs.

New Opportunities to Fund Community Health Workers

Effective January 1, 2024, the Medicare Physician Fee Schedule established a Community Health Integration service that includes, “person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient.” For the first time ever, this Community Health Integration service provision allows Medicare reimbursement for CHWs working under general supervision of a Medicare billing provider.

Why is this important?

CHW programs have been funded through a range of sources that vary widely by state and region, including grants and reimbursement for services, with approximately half of states financing CHW services through Medicaid. Recent Medicare billing and coding changes create a new financing mechanism for CHW programs that serve Medicare enrollees, such as older adults, and offer a new potential pathway to establish and sustain these programs. Notably, while CHWs may be employed by a contracted community-based organization, there must be “sufficient clinical integration” between the Medicare-enrolled provider and the community-based organization to be eligible for Medicare reimbursement.

Resources to Design Community Health Worker Programs for Older Adults

Providers of health care and social services for older adults with complex needs, states focused on engaging and sustaining the CHW workforce, and health plans can look to the following Playbook resources to understand the emerging evidence for CHW programs for older adults and tools for implementation:

Beyond the above resources, the Playbook’s Community Health Worker Programs Collection offers additional evidence on CHW programs, as well as practical strategies to support effective implementation of these programs including financing and reimbursement strategies.

Share Your Community Health Worker Program Resources and Tools

Do you have a resource or emerging best practice related to CHW programs for older adults? Share your experience with the Playbook. We are interested in growing our library of evidence and implementation best practices to help those in the field strengthen and build successful CHW programs in communities across the nation.