Medicaid
Medicaid Financing
PACHW began working with PA Department of Human Services Office of Medical Assistance in April 2023 to develop the draft language for the State Plan Amendment (SPA) that would authorize payment for CHW services under PA Medicaid. DHS initially anticipated the SPA would go into effect on January 1, 2025. In the spring of 2024, DHS delayed their submission of the SPA to CMS to April 1, 2025. As of September 2024, in an unanticipated development, DHS does not anticipate submitting the SPA to the Centers for Medicare and Medicaid Services until at least 2026. Updates will be made available as the process develops.
If you are unfamiliar with how Medicaid is structured and works, please review this resource that was presented by Carl Rush, National CHW Policy Consultant. Click on image above.
State Plan Q+As
What does the related terminology mean?
You can find a quick guide to some of the terminology used throughout the website in relation to CHW financing here.
What is a State Plan Amendment?
A state submits a State Plan Amendment to CMS to make changes to how the state administers their Medicaid program.
What is a State Plan?
A state plan is an agreement between a state and the federal government describing how that state administers its Medicaid program. The plan defines groups of individuals to be covered, services to be provided, and methodologies for providers to be reimbursed. The Pennsylvania Medicaid State Plan is here.
What other states have State Plan Amendments for CHW services?
Below is a map of the states with State Plan Amendments that authorize payment for CHW services or states that are in process of submitting their State Plan Amendment for approval. More information about other states’ financing can be from the National Association of State Health Policy can be found here.
Recommendations for the PA State Plan Amendment
Click on the image above to download the PDF.
PACHW Recommendations for the PA State Plan Amendment for CHW services are listed below:
- An equitable and adequate reimbursement rate should be set by PA DHS.
- Create a Community Health Worker provider type that allows for all CHW employers to equitably attain CHW reimbursement through MA.
- Social Determinants of Health (SDoH) should be recognized as a primary diagnosis code to bill for CHW services as demonstrated in other states.
- The ordering of Community Health Worker services should include CBOs who do not employ Licensed Practitioners of the Healing Arts (LPHA) – PA Code § 5200.3.
- Barriers that disproportionately impact rural communities must be addressed.
States with CHW State Plan Amendments
