Community Health Workers (CHWs) are important partners in helping people get the resources that they need and supporting patients who are dealing with health issues. Too often, though, reimbursement for their services have been supported by grants and time-limited funding.
Increasingly, though, payers are recognizing and resourcing CHW services by creating paths to payment. On January 1, 2024, both Michigan Medicaid and Medicare fee-for-service instituted new codes to pay for CHW servicing. These codes are a starting place that leverage existing mechanisms and maximize what can be done within the scope of program designs. They require some upfront work to set up a process and partnerships among organizations. Still, they improvements on the present system and offer options for organizations that wish to pursue them.
Let’s look at how the new codes work and how they differ. Medicare introduced two Community Health Integration (CHI) HCPCS codes, G0019 and G0022, to pay for CHW services as well as that of other certified or trained auxiliary personnel. Both must be performed under the direction of a physician or other practitioner. G0019 covers 60 minutes of services per calendar month to address social determinants of health (SDOH) need(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating E/M visit. Services can include conducting person-centered assessments, facilitating goal-setting and an action plan, coordinating the receipt of needed services, building self-efficacy skills among others. Code G0022 is used for each additional 30 minutes per calendar month.
Only one (1) provider can bill for CHI services for the same beneficiary, during the same month (first claim in is paid). Both codes require an initiating visit (e.g., evaluation and management, transitional care management, etc.) performed by the billing practitioner who would be furnishing the CHI services. During the initiating visit the billing practitioner would assess and identify SDOH needs that significantly limit the practitioner’s ability to diagnose or treat the patient’s medical condition and establish an appropriate plan. Verbal or written consent must be documented in the medical record. CMS believes that a substantial portion of the work would be done through telehealth or in the office but will permit some via phone. The Medicare Learning Network published a helpful guide to the new health equity codes including the CHI codes that has a wonderful overview of requirements.
Michigan Medicaid’s codes are 98960 to 98962. MDHHS has also published a helpful CHW Beginner guide. Services would be provided via telehealth or in-office but cannot be audio-only (telephone). Medicaid allows the use of their codes for servicing social needs that interfere with treating a medical condition as well as for supporting patients with chronic disease management. Though CMS does not impose quantity limits, Medicaid does. Still, Medicaid’s limits are generous — two hours a day and sixteen visits a month.
Note that neither the Medicare nor Medicaid policies pay CHWs directly. Rather they are paid via an arrangement with a qualified billing provider. Some CHWs will be employed directly by a physician practice or PO. Alternatively, community-based organizations (CBOs) that employ CHWs can contract or form an agreement with a billing provider.
This graphic helps to compare and contrast the Medicare Fee-For-Service and Michigan Medicaid CHW payment policy approaches:
Are these codes worth the upfront effort to seek reimbursement? The answer will depend on each organization’s existing staffing arrangements and interest in pursuing a health equity strategy. Primary care practices with CHWs on staff or who have arrangements with CBOs for CHW staffing are well-suited for billing these new codes. Practices that do not may consider the needs of their patient panel to gauge whether they have a population large enough to support the additional staffing cost. CBOs, too, may consider exploratory conversations with practices or POs to determine if a partnership may be mutually beneficial. Such partnerships require formal agreements; technology and other tools to support clinical integration. However, national organizations like the Partnership to Advance Social Care (PASC) have begun to publish toolkits and sample template contracts to ease the path for organizations that are seeking to partner to provide cross-sector care.
One thing is for certain, though – these new codes are a step in the right direction. Assessing and determining that a health-related social need exists is just a starting point. The navigation and support that community health integration and Community Health Worker services can bring can make all the difference for a patient. Over time, we are hopeful that payment structures become more sophisticated and are integrated into PMPMs or other alternative payment arrangement structures.
In future editions of the Primary Care review, we’ll be examining additional aspects of CHW reimbursement, including the extent to which other payers will adopt CHW billing codes, and the work that MiCHWA is doing on a CHW registry.
Michigan Multipayer Initiatives 