Community health workers (CHWs) are non-clinical staff who work across diverse settings and populations providing services such as navigation, coaching, and social support. In this role, CHWs build trust and leverage shared experience with the communities they serve. Evidence shows that CHW programs improve access to primary care and chronic disease management while reducing use of acute care. While the evidence base is strong, however, reliance on grants, pilots, and public health funding has made these programs challenging to sustain.
The 2024 launch of federal Medicare Community Health Integration (CHI) services, along with a steady increase in states developing state Medicaid pathways for CHW reimbursement, is enabling health care and social services providers to expand access to CHW services. In New York, both the Medicaid CHW benefit and Social Care Network (SCN) contracts, launched in recent years, have enabled Medicaid funding for CHW services. While SCN contracts are time-limited under a Medicaid Section 1115 demonstration waiver, the Medicaid CHW benefit is a permanent state benefit. The fact sheet Funding Community Health Worker Services in New York: Options Under Medicare and Medicaid summarizes these funding streams.
While Medicare and Medicaid coverage present major opportunities to sustain the work of CHWs, many CHW employers — including health care providers and community-based organizations — face challenges accessing these reimbursement options. Recent research has shown low uptake of Medicare CHI services, and a national study found low Medicaid billing for CHW services as of 2020. Data from implementation of the Medicaid CHW benefit in New York tells a similar story: a March 2026 presentation by the state’s Department of Health reported that although CHW service claims and members served have grown steadily, benefit use is modest and primarily concentrated within a small number of billing health systems.
This blog post outlines opportunities for New York policymakers, managed care organizations (MCOs), and other CHW stakeholders to strengthen and expand use of the Medicaid CHW benefit. It draws on lessons from the New York Community Health Worker Reimbursement and Sustainability Learning Collaborative, an initiative led by the Center for Health Care Strategies with funding from the New York Health Foundation, which supported participating health care providers and community-based organizations to build capacity to use Medicaid and Medicare funding for CHW services. Their experiences highlight key insights for policy change and opportunities at the state level.
Although focused on New York, these insights may also be relevant for other states, MCOs, and CHW providers. In addition, the New York Medicaid Community Health Worker (CHW) Benefit: Readiness and Implementation Tool may be a useful resource for organizations exploring implementation of the CHW benefit in New York.
Opportunities to Further Expand Access to CHW Services in New York
1. Provide support to organizations on braiding multiple funding sources for CHW services.
CHW programs often use multiple funding sources, which may be referred to as “braiding” funding, to serve more people, provide more comprehensive services, and improve financial sustainability. In New York, organizations have explored braiding funds for CHW services through various sources, including the Medicaid CHW benefit; Medicaid SCN screening, navigation, and enhanced health-related social needs services; Medicare CHI and other Medicare funding sources (e.g., principal illness navigation); Medicaid Health Home services; grants; and partnerships with health care entities or payers.
CHW employers, however, may struggle to navigate each funding source’s different requirements for covered services, workforce qualifications, supervision, and documentation. One opportunity to reduce administrative burden for CHW providers is to align the covered services and requirements for the Medicaid CHW benefit with those for Medicare CHI, or to “turn on” the Medicare CHI codes in Medicaid, as states such as California, Minnesota, and Washington State have done.
Some CHW employers have also struggled to interpret state billing guidance related to eligibility for health navigation within the Medicaid CHW benefit, as documented in the Community Health Worker Services Provider Manual. Confusion related to this guidance may dampen interest in pursuing the CHW benefit. Greater clarity on what services are billable within the CHW benefit and as SCN services, as well as tools and case studies on how these Medicaid funding streams may be combined, would help organizations more effectively leverage available financing.
2. Align benefit design and rate structure with service delivery models for effective, evidence-based CHW programs.
As learning collaborative participants assessed funding options, they reviewed how each benefit aligns with their CHW service model, billing infrastructure, payer mix and population served, and the reimbursement rates to estimate projected revenue. Medicare CHI services were particularly attractive due to: (1) an expansive list of covered services; (2) no yearly cap on services; and (3) flexibility to provide services on behalf of a patient (i.e., non-face-to-face), such as scheduling specialist appointments or advocating for a patient to receive services when a patient prefers to not be present.
In contrast, the New York Medicaid CHW benefit limits CHW services to approximately six hours per year (12 hours for pediatric populations) and does not reimburse non-face-to-face services. These restrictions limit how providers can use this benefit to support evidence-based CHW programs for patients with complex needs who often require more intensive and sustained support. Additionally, these restrictions diverge from requirements for SCN care navigation services, which are not required to be conducted face-to-face.
The Medicaid CHW benefit restricts participation from some CHW employers and care settings. Billing for these services is not permitted by community-based organizations (CBOs), as well as in Article 31 (mental health services) and 32 (substance use disorder services) facilities. To receive Medicaid reimbursement for CHW services, CBOs must contract with health care entities to deliver services under the CHW benefit or with SCNs to deliver covered services. Additionally, federally qualified health centers cannot bill for the CHW benefit on the same day as another patient visit, and CHW services must be provided on-site. Together, these limitations create challenges for many organizations to use Medicaid reimbursement for CHW services.
State Medicaid rates for CHW services vary widely across the country, and New York CHW employers have expressed concerns about whether the Medicaid CHW benefit reimbursement rates are sufficient to cover operating costs. Medicaid CHW benefit rates are $35 per 30 minutes; Medicare CHI rates in New York state range from approximately $83 to $98 per initial 60 minutes and $52 to $62 per each additional 30 minutes.
To better understand the implications of these rates, state policymakers can seek out insights from CHW employers and other stakeholders to inform future Medicaid rate refinements or managed care requirements. CHW employers, and CHWs themselves, can inform rate development by providing practical feedback on assumptions related to billable time productivity, travel time and costs, supervision, and documentation. Other resources include a published microsimulation model with state and regional benchmarks for rates, and a New York City Department of Health and Mental Hygiene CHW strategic plan and policy agenda which estimated reimbursement needed to support higher benefit uptake.
3. Pursue opportunities to improve communication between CHW providers and MCOs to facilitate increased access to services.
Providers of CHW services can face barriers contracting with and billing multiple MCOs that each have different policies and procedures. This variation can create confusion about how to develop sustainable CHW programs and navigate unique processes across Medicaid MCOs. For example, some MCOs that pay providers a capitated rate (which is a fixed provider payment to cover all services, such as a “per member per month” rate) may allow CHW services to be billed separately (described as a “bill-above”) while others require CHW services to be covered in that existing capitated rate designed to cover a wide range of service activities.
Creating greater consistency and improving communication between providers and MCOs could help address these challenges. Analyzing MCO claims denials, provider billing issues, and barriers to contracting and billing as reported by providers as well as MCOs can help identify problem areas. Based on these findings, potential next steps could include: (1) strengthening MCO contract requirements related to provider communication and contracting; (2) providing training and/or technical assistance to providers and MCOs on effective contracting and partnership strategies; and (3) considering requirements for MCOs to allow for bill-aboves for CHW services under capitated payment arrangements.
4. Sustain infrastructure for training and workforce development.
New York has made important investments to strengthen and align CHW training and workforce development infrastructure. The Medicaid CHW benefit, SCN services, and Medicare CHI services all require that CHWs complete training in the competencies developed by the National Council on CHW Core Consensus Standards. CHW employers also benefit from state investments in the Career Pathways Training Program to support the training pipeline for CHWs.
Despite these investments, many CHW organizations lack information about the landscape of available external training resources for CHWs in New York, including foundational training that covers core competencies as well as specialized trainings and professional development opportunities. For example, CHWs may benefit from specialized trainings to support their work with specific populations of focus or to enhance skills, such as advanced motivational interviewing. CHW employers may also benefit from additional resources to identify and efficiently access high-quality training options, such as: (1) a directory of training programs; (2) MCO investments in training programs for their contracted providers; and (3) investments in training on CHW integration for organizational or clinical teams. State- or MCO-developed trainings on CHW billing may also assist with the uptake of these services.
Looking Ahead
New York organizations are growing and sustaining the CHW workforce through multiple funding streams. New York’s Section 1115 waiver amendment authorizing the SCN networks and the Career Pathways Program will end in early 2027, and providers will need to closely track how reimbursable CHW services may change in the next waiver amendment and identify how other funding sources — such as the Medicaid CHW benefit and Medicare CHI services — can support the sustainability and growth of CHW services. Notably, the 1115 waiver extension request released for public comment in July 2026 proposes to continue delivery of services through SCNs. This upcoming transition will be an opportunity to examine current uptake, identify best practices to expand access, and address common barriers to reimbursement to ensure access to these vital services through Medicaid.
