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Provider Notice: Community Health Workers (IB 22-20)

Date: 07/06/22

Louisiana Healthcare Connections would like to inform providers of updated requirements for Community Health Workers. The added coverage of services provided by Community Health Workers is effective for dates on or after January 1, 2022.

Louisiana Healthcare Connections will cover services rendered to enrollees by qualified community health workers (CHW) meeting the criteria and policy outlined below.

Community Health Worker Qualifications

A qualified Community Health Worker is defined as someone who:

  • Has completed state-recognized training curricula approved by the Louisiana Community Health Worker Workforce Coalition; or
  • Has a minimum of 3,000 hours of documented work experience as a CHW.

Louisiana Healthcare Connections will require providers who employ CHWs to verify and maintain and provide documentation, as requested by LDH, those qualification criteria are met.

Eligibility Criteria

Louisiana Healthcare Connections will cover CHW services if an enrollee has one or more of the following:

  • Diagnosis of one or more chronic health (including behavioral health) conditions;
  • Suspected or documented unmet health-related social need; or
  • Pregnancy.

Covered Services

Covered services include:

  • Health promotion and coaching. This can include assessment and screening for health-related social needs, setting goals and creating an action plan, on-site observation of enrollees’ living situations, and providing information and/or coaching in an individual or group setting.
  • Care planning with the enrollee and their healthcare team. This should occur as part of a person-centered approach to improve health by meeting an enrollee’s situational health needs and health-related social needs, including time-limited episodes of instability and ongoing secondary and tertiary prevention.
  • Health system navigation and resource coordination services. This can include helping to engage, reengage, or ensure patient follow-up in primary care; routine preventive care; adherence to treatment plans; and/or self-management of chronic conditions.

Services must be ordered by a physician, advanced practice registered nurse (APRN), or physician assistant (PA) with an established clinical relationship with the enrollee. Services must be rendered under this supervising provider’s general supervision, defined as under the supervising provider’s overall direction and control, but the provider’s presence is not required during the performance of the CHW services.

Louisiana Healthcare Connections will not restrict the site of service which may include but is not limited to, a health care facility, clinic setting, community setting, or the enrollee’s home. The MCO shall permit delivery of the service through a synchronous audio/video telehealth modality.

Louisiana Healthcare Connections will reimburse only the CPT procedure codes in the ‘Education and Training for Patient Self[1]Management’ section that are provided by CHWs. CHWs will need to follow CPT guidance.

Coverage Limitations

Louisiana Healthcare Connections will not cover the following services when provided by CHWs:

  • Insurance enrollment and insurance navigator assistance;
  • Case management;
  • Direct provision of transportation for an enrollee to and from services; and
  • Direct patient care outside the level of training an individual has attained.

Louisiana Healthcare Connections will reimburse a maximum of two hours per day and ten hours per month per member.

Reimbursement

Louisiana Healthcare Connections will reimburse CHW services “incident to” the supervising physician, APRN, or PA.

Louisiana Healthcare Connections will require a CHW who provides services to more than one enrollee to document in the clinical record and bill appropriately using the approved codes associated with the number of people receiving the service simultaneously. This is limited to eight unique enrollees per session.

“Incident to” Services “

Incident to” services" means services or supplies that are furnished as an integral, although incidental, part of a supervising provider’s professional services. For physicians, “incident to” services include those provided by auxiliary personnel (e.g., medical assistants, licensed practical nurses, registered nurses, etc.), but exclude those provided by an advanced practice registered nurse (APRN) and physician assistant (PA). For APRNs and PAs, “incident to” services also include those provided by auxiliary personnel. For all “incident to” services, auxiliary personnel must only operate within the scope of practice of their license or certification.

Provider supervision must consist of either personal participation in the service or direct supervision coupled with review and approval of the service notes. Direct supervision is defined as the provider is present in the facility, though not necessarily present in the room where the service is being rendered, and immediately available to provide assistance and direction throughout the time the service is performed. For Office of Public Health clinics and services provided by community health workers (CHWs), providers must furnish general supervision, defined as under the supervising provider’s overall direction and control, but the provider’s presence is not required in the facility during the performance of the service.

When an APRN or PA provides all parts of the service independent of a supervising or collaborating physician’s involvement, even if a physician signs off on the service or is present in the facility, the service does not meet the requirements of “incident to” services. Instead, claims for such services must be submitted using the APRN or PA as the rendering provider.

It is inappropriate for a physician to submit claims for services provided by an APRN or PA with the physician listed as the rendering provider when the physician is only supervising, reviewing, or “signing off” on the APRN’s or PA’s Services billed in this manner are subject to post-payment review, recoupment, and additional sanctions as deemed appropriate by Louisiana Medicaid.

Louisiana Healthcare Connections is in updating our Provider Manual to reflect these changes in the next 30 days.