New Report Highlights Medicaid Reimbursement Opportunities for CHR Programs
Community Health Representatives (CHRs) contribute skills and relationships that help improve care coordination and outcomes in American Indian and Alaska Native communities. Medicaid reimbursement for CHRs and other Community Health Workers (CHWs) offers an important opportunity to further sustain this work, but barriers remain in most states.
In 2024, the National CHR Program commissioned the Community Health Worker Collaborative of South Dakota (CHWSD) to conduct an assessment of Fee-for-Service (FFS) Medicaid Coverage for CHW/CHR services. The assessment included a 46-page environmental scan of the 14 states with FFS Medicaid reimbursement for CHW services, using data available through 12/31/2024. The assessment focused on the impact of these policies on CHR programs. Results showed that only five of the 14 states allow CHR programs to bill Medicaid without significant barriers.
Key information collected within the environmental scan includes:
- State Medicaid policies and guidance
- Managed Care Organization summaries
- CHR program structures in each state
- Training, supervision, and certification requirements
- Enrollment and referral processes
- Mode and location of service delivery
- Covered services, documentation needs, reimbursement process and rates, and billing limits
What is FFS Medicaid Coverage?
FFS Medicaid reimburses an enrolled provider for each service delivered. Under Section 1902(a)(30)(A) of the Social Security Act, these payments must align with efficiency, cost-effectiveness, and quality of care standards to ensure access to services comparable to that of the general population.
Barriers to Reimbursement for CHR P
rograms
While progress has been made, CHR programs still face several barriers in most states:
• Only half of the 14 states allow CHR programs that are community-based to enroll and bill Medicaid.
• Eight of the 14 states require provider supervision, which creates a challenge since many CHR programs do not operate under the direct supervision of a licensed provider. Some states do not yet recognize Indian Health Service CHR training as an approved training program.
Currently, the five states where CHR programs can bill Medicaid without major barriers are:
- Arizona
- California
- New Mexico
- Rhode Island
- South Dakota
“As Medicaid billing opportunities continue to progress in our remaining states, the National CHR Program continues to join with partners like the CHWSD, and others across the U.S. to further our common mission to invest in opportunities for our local CHR programs,” said Michelle Archuleta, CHR Consultant and Program Lead for the IHS.
The full environmental scan is available for review on the IHS CHR website.
***The environmental summary scan data was collected in fall 2024 and does not include updates after January 1, 2025. The National CHR Program will work to update the report with information from additional states that have approved fee-for-service reimbursement for CHWs/CHRs after January 1, 2025.
This month’s 
