Effective April 1, 2023, New York State (NYS) Medicaid is covering new benefits for pregnant and postpartum women pursuant to legislation passed in last year’s budget (the 2022-23 Enacted Budget). This includes making available to this population a new benefit of community health worker (CHW) services for care coordination—the first time NYS will offer coverage and reimbursement for CHW services through Medicaid.
This year’s budget, passed on May 2nd, includes a new provision that would, starting in 2024, further expand access to CHW services to almost all Medicaid beneficiaries, including children under 21 and adults with health-related social needs.
This expansion raises the question of how CHWs and the services they offer will be defined under Medicaid. Earlier this month, NYS released the Medicaid State Plan Amendment (SPA) that it submitted to the federal government to enact the new CHW benefit for pregnant and postpartum women. Once approved by CMS, NYS is expected to issue further guidance detailing CHW services and reimbursement. Until then, the SPA provides a first look at this new benefit.
The full SPA is available here. Below is a brief SPG summary of the definition and scope of CHW services as described in this new SPA — as always, if you have questions, please reach out to us at any time to discuss.
CHW Services
The SPA defines a CHW’s function as “to serve as a liaison between health care systems, social service providers, and CBOs to coordinate access to resources.” CHW services include the following three activities:
- Health Advocacy – Addressing the individual’s needs (including needed health care services) by connecting them with community-based resources and programming and supporting them in accessing care.
- Health Education – Evidence-based and culturally-informed education to:
- Optimize the individual’s health;
- Address barriers to accessing health care and/or community resources; and
- Facilitate knowledge, skills, and abilities necessary to support informed decision-making.
- Health Navigation – Assisting the individual to navigate the health system, including:
- Referrals to community-based and health care organizations;
- Screening completion;
- Identification of social care needs;
- Resource coordination; and
- Help with enrollment.
Eligible Populations
Under this SPA, CHW services will be available only to pregnant and postpartum women. Services must be recommended by a physician or other licensed practitioner of the healing arts (LPHA), acting within their scope of practice.
Provider Qualifications
To provide services, a CHW must:
- Have lived experience (pregnancy/birth, housing status, mental health or substance use conditions, other chronic conditions, shared race/ethnicity/language/sexual orientation/community);
- Complete required training and/or work experience, that must include:
- A minimum of 20 hours of training that includes the CDC-endorsed CHW core competencies, and/or
- At least 1,400 hours of work experience as a CHW in formal paid or volunteer roles in the previous three years;
- Complete basic HIPAA and mandated reporter trainings; and
- Work under the supervision of a Medicaid-enrolled, licensed provider.