Bill would let Medicaid pay certified community health workers

UPDATE, March 1: The House sent the bill to the Senate on 94-4 vote.

UPDATE, March 16: The Senate Health & Welfare Committee passed the bill with a committee substitute. 

By Melissa Patrick
Kentucky Health News

A bill to require Medicaid reimbursement for certain services provided by certified community health workers, and streamline their certification process, awaits a vote in the full House. 

CHWs aren't trained medically, but are trained as patient advocates who come from the communities they serve. They help their clients coordinate care, provide access to medical, social and environmental services, work to improve health literacy and deliver education on prevention and disease self-management.

Rep. Kim Moser at a Feb. 17 briefing on HB 525 (News release photo) 

"What makes community health workers unique is not that they are necessarily clinical professionals, rather they are the point guard in helping individuals understand what resources are available," Rep. Kim Moser, R-Taylor Mill, said at a press conference about the bill in a video from the Kentucky Primary Care Association. 

The federal Bureau of Labor Statistics says Kentucky had 1,350 CHWs in May 2020, with an annual average wage of $37,320.

House Bill 525, sponsored by Moser, would require the Department for Medicaid Services to seek federal approval for a state plan amendment, waiver or alternative payment model, including public-private partnerships, for services delivered by certified CHWs.

Teresa Cooper, director of government affairs for the KPCA, said in an e-mail that CHWs are hired as a staff person by a facility, but their services cannot be billed to Medicaid or private insurance. "This legislation would allow the clinic to bill for their services and receive reimbursement or count them in their cost of operations," she said.

The bill would also require CHWs to be employed and supervised by a Medicaid-participating provider and says as of Jan. 1, 2023, "no person shall represent himself or herself as a community health worker unless he or she is certified as such" in accordance with the provisions laid out in the act. 

The bill passed out of the House Health and Family Services Committee, which Moser chairs, on Feb. 24. She pointed to a Kentucky Homeplace study that found between July 2001 and June 2021, community health workers achieved a return on investment of $11.32 saved for every $1 invested in their services. 

"The cost-benefit analysis has shown it to be a very productive use of our taxpayer dollars," she said, adding that because Kentucky expanded Medicaid under the Patient Protection and Affordable Care Act in 2014, the program serves 1.6 million Kentuckians, about one of every three. 

"We know that it's time, because of this Medicaid expansion, to really get more targeted with our Medicaid dollars and work on programs that work," Moser said.

Emily Beauregard, director of Kentucky Voices for Health, said Moser's bill, if passed, could be a "real game-changer" toward providing a sustainable funding source for community health workers in Kentucky. 

"House Bill 525 creates a very, very important pathway to expand our current network of community health workers," Beauregard said.

Pamela L. Spradling, a CHW with Big Sandy Health Care, a federally qualified health center in Prestonsburg that covers five counties, said their CHWs are currently  paid as staff or through grant funding. 

Asked what it would mean for them to be able to bill Medicaid, she said, " That would be huge for us because it would mean sustainability for our program. . . we wouldn't have to constantly be worrying about where the money is going to come from to pay our community health workers." She added that the challenge with grant funding is that when the grant money runs out, so does the CHW program. 

Spradling also spoke to the value of CHWs in changing health outcomes, noting that 62% of their 150 patients with diabetes who have a CHW have seen a 2.5 point reduction in their A1C, and some of them with even higher reductions. An A1C is a blood test for diabetes that measures your average blood sugar levels over the past three months. A normal A1C level is below 5.7%. 

Tiffany Taul Scruggs, a certified CHW and the patient service outreach coordinator for Sterling Health Care, a federally qualified health center based in Mount Sterling, said the CHWs in her facility are either on staff or paid for by grants. 

"If we could bill Medicaid, we could probably hire more community health workers just because we have such a big population in our coverage area," she said. "It would be wonderful if we could bill." 

Scruggs noted several services their CHWs provide, including helping their patients obtain medical equipment, medications and food, helping patients navigate the health care system and providing health education. She added that one their greatest needs is transportation to and from medical appointments. 

"I am proud to say our transportation service has provided just shy of 1,300 rides to our most vulnerable population in 2021," she said in a statement prepared for the House committee. "The team consists of one full-time driver, one part-time driver who was recently hired, two outreach and enrollment specialists, and three community health workers ready to assist our patients when needed." 

Tammy Collett, Cumberland River regional director for Mountain Comprehensive Health Corp. in Whitesburg, said in an e-mail that funding for their CHWs is provided through a grant from Marshall University, The University of Chicago and the Merck Foundation. She said the goal of this grant program is to demonstrate the effectiveness of using CHWs to improve health outcomes and quality of life. 

"It is our hope that payers will recognize the benefit of CHWs and consider coverage for their services," Collett said.