CMS’s Final Rule Expands Reimbursement for Preventive Services

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CMS’s Final Rule Expands Reimbursement for Preventive Services

Medicaid Will Allow Reimbursement for
Community Health Worker Preventive Services!

Community Health Worker (CHW) Health Disparities Initiative partners — have you heard about the CMS ruling announced last month? The Centers for Medicare and Medicaid Services (CMS) created a new rule which allows state Medicaid agencies to reimburse for preventive services provided by professionals that may fall outside of a state’s clinical licensure system, as long as the services have been initially recommended by a physician or other licensed practitioner. The new rule for the first time offers state Medicaid agencies the option to reimburse for more community-based preventive services, including those of CHWs. The rule goes into effect on January 1, 2014.

The announcement of the CMS ruling marked a wonderful moment in time, providing a new opportunity to recognize and advance the role of CHWs! We encourage you to begin discussions with your own national, state and local networks to see how you can contribute to the conversation about reimbursement for preventive services provided by CHWs in your state. Please see below for the actual ruling and links to the relevant sections.

The new rule now states,

“(c) Preventive services means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to—

1. Prevent disease, disability, and other health conditions or their progression;
2. Prolong life; and
3. Promote physical and mental health and efficiency.”

 The citation for the ruling is:

Medicaid and children’s health insurance programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, premiums and cost sharing, exchanges: eligibility and enrollment; final rule. Centers for Medicare & Medicaid Services. 78 Fed Reg 42160 (July 15, 2013). The relevant section is, “a. Diagnostic, Screening, Preventive, and Rehabilitative Services (Preventive Services) (§ 440.130)” (paragraph citation: 78 FR 42226)

The Rule can be found here: PDF

To visit the CHW Health Disparities Initiative website:

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