CurrentNew Mexico Health Care AuthorityPolicy N/A

Community Health Worker (CHW) / Community Health Representative (CHR) preventive services coverage criteria

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Defines New Mexico Medicaid coverage, scope, and payment approach for CHW/CHR services as a reimbursable preventive service under 42 CFR 440.60, effective July 1, 2023, for Medicaid beneficiaries in New Mexico.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyCHW/CHR preventive services coverage criteria

Policy CodePolicy N/A

Change TypeAdded preventive coverage (SPA 23-0011)

Effective Date07/01/2023

Next Review DateN/A

Key ActionProvide CHW/CHR preventive services only when recommended by a licensed practitioner and delivered by credentialed CHWs/CHRs per state credentialing requirements.

SourceLink

POLICY UPDATE CHANGES

Coverage for Community Health Workers/Community Health Representatives (CHW/CHR) was added as a reimbursable preventive service under 42 CFR 440.60 effective July 1, 2023.

07/01/2023effective date for CHW/CHR coverage

SPA 23-0011State Plan Amendment

fee schedulepayment method

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Community Health Worker (CHW) / Community Health Representative (CHR) preventive services coverage criteria

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Sign up for all New Mexico Health Care Authority policy alerts

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyCHW/CHR preventive services coverage criteria

Policy CodePolicy N/A

Change TypeAdded preventive coverage (SPA 23-0011)

Effective Date07/01/2023

Next Review DateN/A

Key ActionProvide CHW/CHR preventive services only when recommended by a licensed practitioner and delivered by credentialed CHWs/CHRs per state credentialing requirements.

SourceLink

POLICY UPDATE CHANGES

Coverage for Community Health Workers/Community Health Representatives (CHW/CHR) was added as a reimbursable preventive service under 42 CFR 440.60 effective July 1, 2023.

07/01/2023effective date for CHW/CHR coverage

SPA 23-0011State Plan Amendment

fee schedulepayment method

$198,713federal impact FFY4

Coverage Criteria for CHW/CHR Preventive Services

Covered Preventive CHW/CHR services

Covered as a preventive service when recommended by an authorized practitioner and performed by credentialed CHWs/CHRs within the defined service scope.

CHW/CHR Preventive Service Coverage: 1) Service is a preventive service as defined by 42 CFR § 440.130(c) and included in the State's list of specified preventive services; 2) Service is provided by a CHW credentialed by the New Mexico Department of Health (grandfathering or training track) or a CHR credentialed through Indian Health Services; 3) Service activities are limited to health promotion/coaching, health system navigation, and clinical support; 4) Service is recommended by a physician or other licensed practitioner acting within scope of practice.

Credentialing details: grandfathering requires 2000 hours; training track requires 100 hours coursework + 40 hours experiential learning; organization certification rollout over 3 years.

The policy explicitly excludes certain activities from CHW/CHR coverage. Non-covered population health activities include community outreach, community organizing, community needs assessments, and community advocacy. The policy also excludes duplicative services such as care coordination activities including performing Health Risk Assessments (HRAs) and Comprehensive Needs Assessments (CNAs), unless those responsibilities are covered through a contract that delegates care coordination to an MCO. Additional exclusions are transportation of members and personal and in‑home care services (for example, childcare, assistance with Activities of Daily Living, and housekeeping).

Services listed under “Non‑covered CHW/CHR services” are not included in the CHW/CHR preventive service benefit and therefore are not medically necessary under this benefit when billed as CHW/CHR services.

Coding and Payment Method

Provider Actions, Billing, and Documentation

Billing Rule

Fee-schedule reimbursement; no prior auth stated

CHW/CHR services are reimbursed under the State’s fee schedule; billing codes and published rates are established by the State. The policy does not state any prior authorization requirement for CHW/CHR preventive services.

Payment method: fee schedule (state-published rates and billing codes).
No explicit prior authorization requirement stated in the CHW/CHR policy.

Note

MCO delegation may cover duplicative care coordination

If care coordination or similar activities are already assigned to an MCO under contract as a delegated responsibility, those activities may be covered by the MCO; otherwise duplicative care coordination activities (e.g., performing HRAs or CNAs) are non-covered under this CHW/CHR benefit.

Background

Community Health Workers (CHWs) and Community Health Representatives (CHRs) provide health promotion and coaching, health system navigation, and clinical support to prevent disease, address barriers, and promote beneficiary health. The policy requires CHWs to obtain credentialing through the New Mexico Department of Health via a grandfathering track (2,000 hours) or a training track (100 hours coursework + 40 hours experiential learning); CHRs must be credentialed through Indian Health Services. Credentialing demonstrates mastery of core competencies including effective communication, interpersonal skills, health coaching, service coordination, advocacy, community outreach and assessment, and clinical support skills. The policy also notes a three‑year rollout for organization certification, which will include oversight of agency supervision of CHWs.

Definitions

Health System Navigation — definition entry

DefinitionProviding information and support to access, understand, and navigate health and social systems and other community resources to promote health, address health care barriers, and health-related social needs.

Who provides itDelivered by credentialed Community Health Workers (CHWs) or Community Health Representatives (CHRs) as part of the CHW/CHR preventive service benefit.

When coveredCovered as a preventive service when recommended by an authorized practitioner and performed within the defined CHW/CHR service scope effective 07/01/2023.

Health Promotion and Health Coaching — definition entry

DefinitionIdentifying strengths and needs, setting goals, and providing action planning, coaching, and training.

Primary activities

Revision History

2023-07-01policy_effective

New Mexico Medicaid added coverage for Community Health Worker (CHW) and Community Health Representative (CHR) services as a reimbursable preventive service effective July 1, 2023.

2024-02-12spa_approvalLatest

State Plan Amendment (SPA) 23-0011 was approved by CMS on February 12, 2024, documenting the addition of CHW/CHR preventive services to the New Mexico Medicaid State Plan.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyCHW/CHR preventive services coverage criteria

Policy CodePolicy N/A

Change TypeAdded preventive coverage (SPA 23-0011)

Effective Date07/01/2023

Next Review DateN/A

Key ActionProvide CHW/CHR preventive services only when recommended by a licensed practitioner and delivered by credentialed CHWs/CHRs per state credentialing requirements.

SourceLink

On This Page

MCO delegation implication: delegated care coordination responsibilities may be covered when a contract exists with the MCO.
Boundary: duplicative services such as HRAs and CNAs are non-covered unless covered via MCO delegation.

Documentation Required

Require practitioner recommendation and CHW/CHR credentialing

Preventive CHW/CHR services must be recommended by a physician or other licensed practitioner acting within their scope of practice. CHWs must be credentialed through the New Mexico Department of Health (either via grandfathering or the training track) and CHRs must obtain credentials through Indian Health Services; credentialing requires demonstration of core competencies.

Practitioner recommendation required: recommendation by a physician or other licensed practitioner within scope of practice.
CHW credentialing options: NMDOH grandfathering (2000 hours) or training track (100 hours coursework + 40 hours experiential).
CHR credentialing: credential through Indian Health Services.
Credentialing core competencies: effective communication, interpersonal skills, health coaching, service coordination, advocacy, community outreach, community knowledge and assessment, and clinical support skills.

Denial Risk

Non‑covered CHW/CHR activities that risk claim denial

Do not bill CHW/CHR benefit for population-health activities, transportation, or personal/in‑home care; these are explicit non-covered items and may result in denial. Specifically avoid billing for community outreach/organizing/needs assessments/advocacy; duplicative care coordination activities (including HRAs and CNAs) unless covered by MCO delegation; transportation of members; and personal/in‑home care (childcare, ADL assistance, housekeeping).

Population health activities (community outreach, organizing, needs assessments, advocacy) — non-covered.
Duplicative care coordination (performing HRAs and CNAs) — non-covered unless delegated to MCO by contract.
Transportation of members — non-covered.
Personal and in‑home care services (childcare, ADL assistance, housekeeping) — non-covered.

Health promotion, goal-setting, individualized action planning, coaching, and training to support preventive health behaviors.

Coverage noteIncluded within the CHW/CHR preventive service benefit when recommended by an authorized practitioner and delivered by credentialed CHWs/CHRs.

Clinical Support — definition entry

DefinitionIncluding assessments, measuring and responding to vital signs, providing feedback to medical providers, and care coordination.

Role in careSupports clinical teams by collecting assessment data, monitoring vital signs, and communicating findings to providers for care coordination.

Coverage contextClassified as an allowable CHW/CHR activity within the preventive service benefit when performed by credentialed CHWs/CHRs under practitioner recommendation.