The Medicare Physician Fee Schedule (PFS) sets the payment rates for doctors and providers each year. The latest update to the Medicare Physician Fee Schedule (PFS) includes exciting new changes advancing health equity including expansion of behavioral health services, the President’s Cancer Moonshot, support for family caregivers, acceleration of value-based care, and reimbursement for Community Health Workers (CHWs). The inclusion of reimbursement for services provided by CHWs enables providers to address underlying social determinants of health by integrating CHWs and other auxiliary personnel, either directly employed or through partnerships with community-based organizations, into their care teams.
These changes are in line with Health and Human Services (HHS) Equity Action Plan which emphasizes the Administration’s commitment to reducing health disparities and addressing health equity.
Over 65 million Americans are enrolled in Medicare and could potentially benefit from this change by becoming eligible to receive Community Health Integration (CHI) services provided by a Community Health Worker. These services address specific barriers caused by health-related social factors that impede successful diagnosis and treatment of a health problem leading to improved health outcomes. Beyond this immediate impact, historically, payment reforms in Medicare set the stage for wider adoption in commercial insurance coverage, transforming the United States’ entire healthcare system. In this blog, we’ll explore the implications of this policy change for patients, providers, CHWs, health plans, and community-based organizations.
Acknowledging the Importance of a Community Health Worker in the Health Care Delivery System
The American Public Health Association defines a CHW as a “frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” CHWs are community-informed and serve an important role in navigating between health and social services and their communities by helping patients facilitate access to services. Because of their deep roots in the communities they serve, CHWs also improve the cultural competency of healthcare service delivery. Activities that CHWs engage in can be as varied as the definitions or titles for CHWs, but in terms of the services now reimbursable by Medicare, these are defined and referred to as Community Health Integration (CHI) services in the final PFS.
Defining Community Health Integration Services
In the 2024 Medicare PFS final rule, Community Health Integration (CHI) services are defined in a broad range of activities conducted by CHWs or similar auxiliary personnel. The services include addressing social determinants of health (SDoH) like housing, food and nutrition access, and transportation needs that impact a patient’s ability to manage health conditions and adhere to treatment plans.
What is Reimbursable as a Community Health Integration (CHI) Service
- Conducting Person-Centered Assessments to better understand the individualized context of the intersection between the SDoH needs and the health problem(s) addressed in the initiating visit with their provider.
- Care Coordination including coordinating necessary services from healthcare practitioners, home- and community-based service providers, and social service providers.
- Health Education and Advocacy to help patients understand health education provided by their treatment team and educate them on participating effectively in medical decision-making, including patient self-advocacy skills.
- Healthcare Access Navigation to assist patients in navigating the healthcare system, including identifying appropriate providers for clinical care and helping secure appointments.
- Facilitation of Behavior Change to help the patient make necessary behavioral changes to meet the diagnosis and treatment goals and motivate patient participation in care.
- Social and Emotional Support to help patients cope with the problems addressed in their healthcare visits, adjust their daily routines, and better meet diagnosis and treatment goals.
- Leveraging Lived Experience, when applicable, to provide support, mentorship, or inspiration to patients, aligning with the treatment goals.
This definition of CHI services is comprehensive in recognition of the multi-dimensional role CHWs have in bridging gaps between traditional healthcare services and the broader social needs of patients.
For these services to be reimbursable, they must be directly tied to a diagnosis or treatment of a medical problem identified during a visit with a healthcare provider. CMS also directs that CHI services must be documented in the patient’s medical record in relation to the specific social determinant of health need(s) identified as impeding diagnosis or treatment.
Understanding the Impacts
Certification Requirements for CHWs
Medicare does not mandate specific national certifications for CHWs to be eligible for reimbursement but defers to state-level regulations. For CHWs residing in states without certification requirements, the final rule specifies that CHWs must be trained on the following topics: patient and family communication and capacity-building, service coordination and system navigation, patient advocacy and more.
The services reimbursed and the training requirements reflect the professional consensus regarding CHW core competencies. The identification of these competencies will inform existing and developing CHW training programs, although CMS stopped short of designating a set number of training hours required.
Credentialing and Billing Responsibilities
Individual CHWs will not be directly credentialed for billing. Instead, healthcare providers will be responsible for billing for CHI services. This arrangement underscores the collaborative nature of CHWs’ roles, working as part of a broader healthcare team under the direction and supervision of a licensed healthcare provider.
CHWs do not need to be directly employed by the billing provider. Providers have the flexibility to contract with community-based organizations that employ CHWs. This flexibility acknowledges that there are many CBOs with existing CHW programs that are experienced in training and supervising CHWs and may also make the most logical supervisor of CHWs. Whether CHWs are employed directly or through CBOs, close collaboration will be necessary to ensure compliance and appropriate reimbursement.
Initiation of CHI Services
CHI services cannot be initiated by the CHW or a Community Based Organization. Only the healthcare provider actively involved in the patient’s care, specifically for diagnosis or treatment of a health issue, can initiate CHI Services. This reinforces the requirement that CHI services are always in direct response to a specific diagnosis or treatment plan.
For example, a patient visits their provider for diabetes management. During that appointment, the provider learns that the patient struggles with food insecurity and transportation, which hinders his ability to maintain a consistent diet and attend regular follow-up appointments. In response, the provider can now initiate CHI services by referring the patient to a CHW employed by a local CBO partnered with the practice. The CHW can connect the patient to local food assistance programs, arrange transportation for his medical appointments, and help him understand the provider’s health education materials.
The Latest Medicare Physician Fee Schedule Moves the Delivery System Forward in Health Systems Change
Inclusion of CHI services in the latest Medicare PFS follows an established trend that has been seen in Medicaid for decades. According to the Kaiser Family Foundation’s 2022 annual Medicaid budget survey, 29 states allowed Medicaid payment for services provided by CHWs as of July 1, 2022. The mechanisms for accomplishing this varied by state and include state plan coverage, managed care arrangements, and the use of Section 1115 demonstration waivers.
This shift to pay for Community Health Worker services in Medicare and Medicaid is a clear recognition of this vital workforce and, that at the end of the day, all healthcare is local.
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