Community Health Worker (CHW) Bulletin Notification
In accordance with Bulletin MMP 23-74, Meridian Health will now cover community health worker (CHW) services as a component of Medicaid services for dates of service on and after January 1, 2024. Community Health Worker services are provided as preventive services pursuant to 42 CFR Section 440.130(c).
A CHW/community health representative (CHR) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. CHW services focus on preventing disease, disability, and other chronic health conditions or their progression and promoting physical and mental health. These services are designed to be person-centered, and patient driven, with a focus on beneficiary empowerment, fostering self-advocacy skills to promote personalized and effective diagnosis or treatment.
As required by federal regulations at CFR 440.130(c), CHW services must be recommended by a licensed healthcare provider. Healthcare providers qualified to recommend CHW services include but are not limited to the following:
- Physician
- Physician Assistant
- Advanced Practice Registered Nurse
- Registered Nurse
- Licensed Master Social Worker
- Dentist
- Psychiatrist or Psychologist
Licensed healthcare providers recommending CHW services are not required to be part of the beneficiary’s healthcare team, but collaboration is highly encouraged.
Referring/Requesting a Community Health Worker for Members:
- On the Provider Portal the Social Determinants of Health (SDoH) Assessment can be completed for the member which will trigger a CHW to make contact
- Download SDoH Assessment from the website, complete form, and fax to 833-667-1288. The form can be found on the Community Health Worker Page under "Request a CHW"
Covered Services and Reimbursable Codes
- CHW services are to be reported as follows:
- 98960 (education and training for patient self-management; individual patient)
- 98961 (education and training for patient self-management; 2-4 patients)
- 98962 (education and training for patient self-management; 5-8 patients)
- These codes are to be reported in 15-minute increments and must be billed with the CG modifier to be considered for payment. One 15-minute increment equals one unit of service. The group size may not exceed 8 beneficiaries.
- No Prior Authorization will be required for the codes specified above
- Providers are asked to insert the following into the notes/comments section of the claim to provide additional information about the services being performed:
| Claims Notes Section | Description (Based on Beneficiary Need - Covered Services) |
|---|---|
| C100 | Chronic Health Condition – Health System Navigation and Resource Coordination |
| C200 | Chronic Health Condition – Health Promotion and Education |
| C300 | Chronic Health Condition – Screening and Assessment |
| C400 | Chronic Health Condition – Other |
| S100 | Social Need – Health System Navigation and Resource Coordination |
| S200 | Social Need – Health Promotion and Education |
| S300 | Social Need – Screening and Assessment |
| S400 | Social Need – Other |
| P100 | Pregnancy and up to 12 months Postpartum – Health System Navigation and Resource Coordination |
| P200 | Pregnancy and up to 12 months Postpartum – Health Promotion and Education |
| P300 | Pregnancy and up to 12 months Postpartum – Screening and Assessment |
| P400 | Pregnancy and up to 12 months Postpartum – Other |
| T100 | Other Eligibility – Health System Navigation and Resource Coordination |
| T200 | Other Eligibility – Health Promotion and Education |
| T300 | Other Eligibility – Screening and Assessment |
| T400 | Other Eligibility – Other |
- CHW services are limited to 2 hours (8 units) per day and 16 visits per month, for a maximum of 32 hours (128 units) per month, per beneficiary. This limit may be exceeded based on medical necessity determined in collaboration with the recommending licensed provider and requires prior authorization.
FQHC, RHC, THC and Tribal FQHC Reimbursement
- FQHC, RHC, THC, and Tribal FQHCs furnishing eligible CHW services will be reimbursed outside of the Prospective Payment System (PPS) methodology or All-Inclusive Rate (AIR) methodology at the applicable Medicaid fee screen rates.
- CHW services billed by clinics should be billed on the institutional claim form using the Group/Organizational - Type 2 clinic specialty enrolled NPI.
- On the institutional claim form, the Attending Provider field line should include an eligible Individual – Type 1 provider, per bulletin MSA 21-47.
- The Individual – Type 1 NPI of the CHW rendering the actual service to the Medicaid MMP 23-74 Page 8 of 9 beneficiary at the clinic should be listed in the Other/Rendering field line (referring/rendering/ordering).
Health Homes
- A CHW can serve as a member of the Health Home Care Team (HHCT) as well as be a staff member of the FQHC/Designated Health Home Partner.
- If Medicaid is billed for CHW services and the Health Home is claiming a core service for a month it is important that the services are separate and distinct. CHW services may not be duplicative of the monthly core services being claimed by a Health Home.
Additional information can be found by referencing the Final Bulletin MMP 23-74-CHW.
If you have questions, please contact our Provider Services Department at:
- Meridian Medicaid: 1-888-773-2647 (TTY 711)