Community Health Worker Services
Community Health Worker Program Changes
The Rhode Island Medicaid Program has updated requirements for Community Health Worker (CHW) services as part of ongoing efforts to strengthen program integrity, align with national best practices, and ensure high-quality, medically necessary care.
Rhode Island Medicaid CHW Services involve direct, non-clinical support provided by certified CHWs to Medicaid beneficiaries. These services include health promotion and coaching, health education, training, and health system navigation intended to improve health outcomes, promote preventive care, and support individuals in navigating healthcare and social services systems.
Effective May 19, 2025, Medicaid only reimburses services with direct engagement and clear medical necessity documentation. Medicaid has discontinued reimbursement for CHW services not delivered directly to the Medicaid beneficiary.
To ensure billing accuracy and compliance, EOHHS has implemented additional safeguards, including enforcing HIPAA-compliant service delivery settings, preventing billing for overlapping or redundant services, appropriate use of telehealth, and strengthening documentation requirements to align with federal Medicaid rules. Please see below for a detailed timeline of these changes.
Timeline of CHW Program Changes
Effective May 19, 2025:
- Daily service limit of no more than two (2) hours per day per beneficiary. Prior authorization required for additional hours.
- Standing orders no longer allowed.
- All CHW services must be individually authorized by a Licensed Practitioner of the Healing Arts (LPHA) who has direct knowledge of the beneficiary’s needs.
- Enhanced billing rate (modifier U3) for new patient visits are no longer applicable.
- Discontinuation of multidisciplinary care and collateral services.
Effective May 23, 2025
- All new and revalidating CHWs must complete a Bureau of Criminal Identification (BCI) background check as a condition of Medicaid enrollment.
Effective July 1, 2025:
- A monthly limit of no more than twelve (12) hours per month (48 units) per Medicaid beneficiary. Prior authorization required for additional hours.
- CHW services must be billed under newly designated service categories using specific procedure codes: S9445 (Individual Health Promotion & Coaching or Health Education and Training), S9446 (Group Health Promotion & Coaching or Health Education and Training), and H0038 (Individual Health System Navigation).
- Group-based CHW sessions are limited to no more than eight (8) Medicaid beneficiaries per session. Individualized documentation and LPHA authorization are required for each participant.
Effective October 1, 2025:
- All CHWs must obtain full certification by the Rhode Island Certification Board (RICB). Transitional certification pathways will sunset, and CHWs must achieve full certification by this date to remain eligible. Note: transitional certification eligibility will end of May 19th and all newly enrolled CHWs must be fully certified by May 19th.
- All CHWs must possess a valid National Provider Identifier (NPI).
- CHWs must be affiliated with a group to be able to bill for services.
- CHWs must complete a National Background Check.
EOHHS has rescinded the requirements for electronic visit verification requirements effective July 1, 2026, however, CHWs must comply with additional documentation and safety standards for any services delivered in beneficiaries’ homes.
Summary of Key Dates
|
Change |
Effective Date |
| 2-Hour Daily Service Limit (Prior Authorization required for >2 hours/day) | May 19, 2025 |
| Sunset of U3 Modifier | May 19, 2025 |
| No Standing Orders Allowed | May 19, 2025 |
| Collateral Services and Multidisciplinary Care Discontinued | May 19, 2025 |
| BCI Background Check Requirement | May 23, 2025 |
| 12-Hour Monthly Service Limit (Prior Authorization required for >12 hours/month) | July 1, 2025 |
| New Billing Codes and Categories (S9445, S9446, H0038) | July 1, 2025 |
| Group Size Limit (8 beneficiaries) | July 1, 2025 |
| Full RICB Certification Required for Transitional Certification | October 1, 2025 |
| NPI Required | October 1, 2025 |
| CHW Group Affiliation Required | October 1, 2025 |
Resources
All compliance dates can be found in the revised CHW Provider Manual and Section 9 (Compliance Calendar) for detailed reference. The Rhode Island Medicaid CHW Program Manual (Version 4.2) is available here.
La versión 4.2 del Manual de CHW en español ya está disponible aquí.
CHW Information Session: August 28, 2025
EOHHS will have two information sessions for CHWs regarding the new changes to the Medicaid CHW Program.
- English session on August 28, 10 a.m. - 11:30 a.m.
- Sesión en español el 28 de agosto a 1:30 p.m. - 3 p.m.
Important Forms:
CHW Certificate of Medical Necessity
Rhode Island National Background Check Application Form
For additional information, please contact:
EOHHS Provider Services: riproviderservices@gainwelltechnologies.com