Medicaid
Medicaid Financing
PACHW began working with PA Department of Human Services Office of Medical Assistance (PA DHS OMAP) in April 2023 to develop the draft language for the State Plan Amendment that will authorize payment for CHW services under PA Medicaid for the first time ever. It is anticipated that PA DHS will submit the State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS) for approval on April 1, 2025, with a newly anticipated start of July 1, 2025 pending CMS approval. Other recommendations 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.
- What CHW services will be covered?
- CHW definition under the State Plan Amendment
- When will the Amendment go into effect?
The CHW services to be covered under the State Plan Amendment have not yet been finalized. As it stands currently, the following services will be covered but these services may changed based on the final application and approval process:
- Health system navigation and resource coordination
- Health education and promotion
- Health advocacy
- Screening and assessment
This definition has not been finalized and may change based on the final application and approval process.
A Community Health Worker (CHW) is a trusted member of their community who leverages lived experience to contribute to improved health outcomes. CHWs serve the communities in which they reside or communities with which they may share ethnicity, language, socioeconomic status, or life experiences.
It was originally anticipated that DHS would submit the State Plan Amendment to the Centers for Medicare and Medicaid Services (CMS) in the fall of 2024 with implementation in January 2025. As of April 2024, the timeline for anticipated submission to CMS is April 1, 2025 with implementation July 1, 2025.
States with CHW State Plan Amendments
