What’s Next for CHWs: Integrating Medicare Reimbursement and Broadening Access 

April 24, 2024 |  By Mary Hunt Moore 

Share This:
patient and healthcare worker engaging in important discussion

Back in November, we covered the inclusion of services provided by Community Health Workers (CHWs), dubbed Community Health Integration (CHI) services, in the latest Medicare Physician Fee Schedule (PFS). The move to begin reimbursing services provided by CHWs in Medicare reflects a recognition of their integral role in addressing underlying social determinants of health (SDOH). This decision broadens the opportunity for CHWs to serve a critical population with reimbursement from Medicare. In this update, we’ll explore the latest CMS guidelines for providers implementing billing for CHI into their practices and legislative efforts that aim to enhance access to and increase the affordability of CHW services for patients. 

Clarifying the Billing Process 

The Centers for Medicare & Medicaid Services (CMS) issued detailed guidance regarding billing for CHI services in a recent Medicare Learning Network publication for providers, Health Equity Services in the 2024 Physician Fee Schedule Final Rule and in a Health-Related Social Needs FAQ that addresses some of the most common billing questions around CHI services. These publications specify how health care providers can bill for CHW services, including new G codes—G0019 for the first 60 minutes of CHI services per month, and G0022 for additional time in 30-minute increments. There is no upper limit on the frequency of these services, but only one provider may bill during a given month.  

Operational Details of CHI Service Delivery 

The CHI services model presented in the PFS and further elucidated in the CMS-issued guidance for providers, underscores a collaborative approach to addressing Social Determinants of Health (SDOH) by requiring close coordination among health care providers, Community Health Workers (CHWs), and social service organizations. Initiation of CHI services occurs during a routine health care provider visit, such as an Evaluation and Management (E/M) session or an Annual Wellness Visit (AWV), where SDOH barriers are identified. Notably, Medicare does not directly reimburse CHWs. Instead, CHI services are billed as incidental to the primary health care provider’s services, emphasizing the integrated role of CHWs within health care teams. Effective CHI service delivery hinges on careful documentation of SDOH needs and bidirectional communication channels across health care and community systems to manage and exchange vital patient information securely and efficiently. 

Strengthening Health Equity Through CHI Services 

At the heart of these updates is a clear focus on health equity. Reimbursement for CHI services enables health care providers to engage more deeply with the communities they serve by working in tandem with CHWs, many of whom are employed by community-based organizations.  The inclusion of CHI reimbursement in Medicare is also vital for the sustainability of CHW organizations, which often rely on a patchwork of funding sources to maintain their operations.  

Legislative Efforts to Expand Access to Community Health Workers 

As Medicare embraces CHW services, legislative efforts like the Community Health Worker Access Act proposed by U.S. Senator Bob Casey aim to broaden access to CHWs by improving reimbursement for CHW services in Medicare and supporting the integration of CHW services in Medicaid. This would be achieved by: 

  1. Ensuring that patients can access CHW services without incurring out-of-pocket costs through proposed amendments specified in the bill that adjust payment schedules and deductible requirements. Currently, CHI services are subject to the Part B deductible and 20% cost-sharing after the deductible has been met. Eliminating cost-sharing will increase affordability and therefore access to these services for those who would benefit the most. 
  2. Creating an optional Medicaid benefit for CHW services available to states through a state plan amendment. This would allow states to integrate CHW services into Medicaid with an increased FMAP, providing additional federal funding to encourage states to adopt this model. 

    The legislation recognizes the important role CHWs play in delivering preventative services which can reduce overall health care costs and cites a randomized control trial that found that CHWs could save Medicaid $4,200 per enrollee each year.  

    Community Health Workers (CHWs) play a key role in transforming health systems, bridging existing gaps between clinical care and community-based supports to tackle SDOH needs. Transform Health is committed to bringing you the latest updates and insights as these changes develop.  

    Transform Health is a nationally certified women and minority led health care consulting firm. Reach out to us today if you would like to work together. Contact Heather Bates, COO, and VP of Stakeholder Engagement at heather@transformhc.com We would love to hear from you!