Community Health Workers (CHW) are an increasingly established workforce in state, federal, and local policymaking. CHWs work within their communities as a trusted source of health education, individual and community capacity building, and connection to needed health services, resources and supports. Given this vital role, state policymakers continue to explore various policy levers to increase access to CHW services.
The National Academy for State Health Policy (NASHP) recently completed a scan of all 50 states and Washington, D.C., to update the State Community Health Worker Policies tracker. This tool tracks changes in state CHW policy from October 2024 through March 2025 according to the following categories: state definitions, state CHW governance, certification and training, Medicaid reimbursement, other funding mechanisms, key partnerships, and state legislation.
Major trends included a notable uptick in Medicaid coverage and legislation providing for new governance structures, certification, training and reimbursement opportunities, and enhanced partnership opportunities with CHW leaders (via CHW associations and networks).
Trends in Medicaid Approaches
Medicaid reimbursement and investment approaches, including through State Plan Amendments, Medicaid Section 1115 demonstration waivers, and managed care organization (MCO) expenditures, remain popular state strategies to develop sustainable access to CHW services for Medicaid enrollees.
State Plan Amendments
States continue to adopt State Plan Amendments (SPA) to reimburse for CHW services through Medicaid. During this update, four states (Colorado, Georgia, Oklahoma, and Washington) had SPAs approved by the Centers for Medicare and Medicaid Services to support CHW services.
Since the first SPA for CHW services was approved in Minnesota in 2008, 20 states have received approval for Medicaid SPAs authorizing reimbursement for CHW services. SPA development may be authorized via state legislation or initiated through state Medicaid agencies. While there are some exceptions, SPAs often feature fee-for-service (FFS) reimbursement through 9896x Common Procedure Terminology (CPT) billing codes, which focus on health education. There is no set methodology for calculating a reimbursement rate for CHW services. However, some states, such as South Dakota, consider factors such as driving long distances when determining a rate. For more information about developing and implementing SPAs for CHW reimbursement, please review NASHP’s FAQ.
Medicaid Section 1115 Demonstration Waivers
As of this update, 15 states have approved Section 1115 demonstration waivers to support CHW services. Of the 10 most recent approvals, seven were focused on incorporating CHW services into pre-release services for incarcerated individuals.
Re-entry programs illustrate the value of lived experience as a qualification for CHWs. NASHP’s Reentry Learning and Action Network (in collaboration with the Health and Reentry Project) highlighted a few examples of programs states may consider as they build CHWs into justice-involved work, along with key lessons in engaging people with lived experience of incarceration. For example, programs such as the Transition Clinics Network (TCN), active in 14 states, attribute their success in re-entry services in large part to their CHWs’ background as justice-involved individuals.
Medicaid Adoption of Medicare Community Health Integration and Principal Illness Navigation Codes “G Codes”
The 2024 Physician Fee Schedule introduced Community Health Integration (CHI) and Principal Illness Navigation (PIN) codes, allowing CHW services to be billed through Medicare. The CHI and PIN “G codes” are part of the Healthcare Common Procedure Coding System and are newly available to states, most of whom use the CPT reimbursement codes 9896x. CHI services are intended to address health-related social needs associated with a medical diagnosis, regardless of the nature of that diagnosis. PIN services are used to address the support and navigation needs of individuals with serious illness, regardless of whether that individual has identified health related social needs.
While there has been limited uptake of CHI and PIN codes within Medicare to date, several states, including California, Minnesota, and Washington, have adopted these billing codes into their Medicaid programs. Incorporating these codes allows CHWs to provide a more comprehensive array of services authorized under the supervision of a billing provider. States may also consider how adopting G codes creates an opportunity to align reimbursement strategies across Medicaid and Medicare, especially for dually eligible individuals.
Case Example: Washington State
Washington undertook a systematic review process in establishing its CHW services benefit in Medicaid:
Reimbursement approach: Washington’s SPA (approved in 2024) allows for coverage of preventative services and other diagnostic, screening, preventative and rehabilitation services, and the state organizes provider guidance for Medicaid billing around CHI and PIN codes adapted from the Medicare Part B Physician Fee Schedule (2024). Washington is the first state to build its CHW reimbursement policies (and data analysis) around those codes1. As with the Medicare CHI and PIN options, eligibility is determined by the supervising provider through a screening as part of an “initiating visit” with the provider. Unlike most other states, claims for CHW services are filed under the clinical organization’s National Provider Identifier number rather than an individual clinical provider number. The provider’s written recommendation for provision of CHW services may be in the form of a notation in the patient’s electronic health record.
Proposed FFS billing rates for CHW services were set after reviewing practices in a half dozen other states. Providers are also invited to negotiate actual rates with Medicaid MCOs.
CHW Qualification Requirements: Since Washington does not have a state-level certification program for CHWs, required CHW qualifications for Medicaid include 2,000 hours of supervised CHW work experience, “lived experience that aligns with and provides a connection between the CHW and the community being served,” and “some additional training” (aligned with C3 recommendations). Providers may bill for services of a CHW who does not initially meet these requirements, but that CHW must obtain such qualifications within 18 months. This grace period provision, first used by Rhode Island and also adopted by California, encourages employers to retain or hire individuals with lived experience or other key attributes and not rely solely on completion of formal training.
Unlike other states, Washington requires obtaining patient consent before providing CHW services; consent may be verbal or written, but must be documented, most likely in the electronic health record. The provider must also file a prior authorization request prior to billing, which is not the case in most other states.
Managed Care Organization Expenditures for CHW Services
Medicaid MCOs continue to play a significant role in providing CHW services.
States have the option to use MCO contract language to permit, incentivize, or mandate spending for CHW services in the absence of a SPA or 1115 demonstration waiver. In this circumstance, the services are not considered Medicaid benefits or covered services. For example, Oklahoma has recently implemented managed care in Medicaid. Medicaid MCOs (called Contracted Entities, or CEs) have begun to hire CHWs directly, in some cases before their contracts were fully implemented and in advance of the state’s recently approved SPA. Qualitative evidence points to Medicaid MCOs investing in CHW services through administrative funds as part of their own business strategy, though this area warrants further research. This trend may represent an interim or short-term strategy for states since financing CHWs through Medicaid MCO contract requirements has been superseded by SPA approaches.
Medicaid regulations also allow states to designate Medicaid MCO CHW spending as quality improvement and part of “total cost of care” (actual spending on member health care benefits) and not administrative spending. To date, only Texas has used this strategy, with authorizing legislation effective in September 2023. As of this writing, no data were available on uptake of this provision.
Recent State Legislation
Over the past two years, six states (Arkansas, Connecticut, Illinois, Mississippi, New Hampshire, and North Dakota) enacted legislation mandating or authorizing reimbursement for CHW services through Medicaid. Other states reported they were developing a SPA that may require authorizing legislation.
State CHW Governance
This new trend category has been added to capture the landscape of state-level governance structures dedicated to CHW policymaking and programming. Kansas, Kentucky, Massachusetts, Mississippi, New Mexico, Oklahoma, and Texas reported a dedicated state office of CHWs. Many other states without such an official government unit have reported supporting state CHW efforts via designated staff positions in departments of public health and/or Medicaid.
Understanding how state governments incorporate CHW programs is key to identifying opportunities for cross-agency collaboration and resource alignment, such as:
- Medicaid reimbursement approach aligned with state grants supporting CHW infrastructure, hiring, and capacity building (e.g., from public health, maternal and child health, behavioral health, and aging agencies);
- Leadership buy-in and strategic planning regarding health care workforce needs in the state – especially in hard-to-reach communities; and
- Coordination across payers (such as Medicaid, state employee programs, and commercial insurers) and other private investments.
NASHP will continue to monitor developments of state CHW policy. Future trend reports may provide further details on these state actions. Please contact Megan D’Alessandro (mdalessandro@nashp.org) if you are interested in learning more about NASHP’s CHW policy work.
Acknowledgments
This brief was coauthored by Carl Rush, principal consultant for Community Resources, LLC.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
