RE: HEALTH HOMES ADDED TO ELIGIBLE PROVIDERS FOR COMMUNITY HEALTH WORKERS
IMPACTED PLANS: Medicaid and HIV SNP
TO: ALL PROVIDERS
Dear MetroPlusHealth Provider,
Effective April 1, 2025, the New York State Department of Health has released notice that Health Homes will be added to the list of eligible providers for community health worker (CHW) services. MetroPlusHealth will expand coverage to include members eligible for CHW services are as follows:
- health advocacy
- health education
- health navigation supports aimed at improving health outcomes
- health literacy to prevent the development of adverse health conditions, injury, illness.
A Community Health Worker (CHW) is a public health worker who reflects the community served through lived experience that includes pregnancy and birth; housing status; mental health conditions; substance use or other chronic conditions; shared race, ethnicity, language, and/or sexual orientation; or community of residence.
The requirements for our Medicaid members to get CHW services must be:
- a child under 21 years of age;
- pregnant and postpartum members during pregnancy, and up to 12 months after pregnancy ends, regardless of the pregnancy outcome;
- adults with chronic conditions;
- involved in the justice system within the past 12 months;
- have an unmet health-related social need in the areas of housing, nutrition, transportation, or interpersonal safety
- exposed to community violence or have a personal history of injury sustained as a result of an act of community violence, or who are at an elevated risk of violent injury or retaliation resulting from another act of community violence.
Note: If a member is already enrolled in a Health Home (HH) program, a HH Care Coordination Organization, or if they receive care coordination through a community behavioral clinic or Assertive Community Treatment (ACT), they cannot receive CHW services. HHs may be reimbursed for the provision of CHW services when provided to NYS Medicaid members before or after they receive other care management services from these entities and not when they are enrolled in a HH program.
Billing Guidelines:
A CHW is not recognized as a licensed or certified NYS Medicaid provider.
CHW services must be recommended by a physician or other licensed practitioner of the healing arts, acting within their scope of practice under State law, to be eligible for NYS Medicaid reimbursement.
Health Home programs can only be reimbursed for CHW services before or after the member receives care management services.
See below for rate chart:
| HH Rate Code | Description | Unit |
|---|---|---|
| 1886 CHW | Self-management education and training face-to-face using a standardized curriculum for an individual NYS Medicaid member, each 30 minutes. |
|
| 1887 CHW | Self-management education and training face-to-face using a standardized curriculum for two to four NYS Medicaid member, each 30 minutes. | |
| 1888 CHW | Self-management education and training face-to-face using a standardized curriculum for five to eight NYS Medicaid member, each 30 minutes. | |
| 1889 CVP CHW | Self-management education and training face-to-face using a standardized curriculum for an individual NYS Medicaid member, each 30 minutes. | |
| 1890 CVP CHW | Self-management education and training face-to-face using a standardized curriculum for two to four NYS Medicaid member, each 30 minutes. | |
| 1891 CVP CHW | Self-management education and training face-to-face using a standardized curriculum for five to eight NYS Medicaid member, each 30 minutes. |
Please refer to Expanded Eligibility for Community Health Worker Services | MetroPlusHealth for more information.
If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].