Medicaid CHW Services Updates June 2025
Medicaid CHW Services Updates: Rhode Island has released major state plan amendments (SPA) updates to the Medicaid CHW benefit, including new billing limits, service definitions, and certification requirements.
Key Changes Now in Effect:
- Refined Service Definitions: CHW services must fall under three categories: 1) Health Promotion & Coaching, 2) Health Education & Training, and 3) Health System Navigation & Resource Coordination.
- Elimination of Non-Direct Services: Collateral services and multidisciplinary care planning are no longer reimbursable under Medicaid.
- Service Limits: CHW services are now limited to 2 hours per day and 12 hours per calendar month per Medicaid beneficiary. Prior authorization is required to exceed these limits.
- Referral Requirements: All CHW services must be authorized by a Licensed Practitioner of the Healing Arts (LPHA) and tied to a specific diagnosis or clinical risk. General standing orders or blanket referrals are not permitted.
- Updated Certification Requirement: Effective October 1, 2025, all currently enrolled CHWs must be fully certified by the Rhode Island Certification Board (RICB) to remain eligible for Medicaid reimbursement. Transitional certification pathways will no longer be accepted after this date.