Community Health Worker Services

Community Health Worker Program Changes

Effective May 2025, the Rhode Island Medicaid Program will implement 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 will only reimburse services with direct engagement and clear medical necessity documentation. Medicaid will discontinue reimbursement for CHW services not delivered directly to the Medicaid beneficiary 

To ensure billing accuracy and compliance, EOHHS will implement 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.
• Standing orders will no longer be 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 will sunset and no longer be 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.
• 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 will be limited to no more than eight (8) Medicaid beneficiaries per session. Individualized documentation and LPHA authorization will be 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). 

Effective July 1, 2026: 

• Electronic Visit Verification (EVV) will be required for CHW services delivered in a home setting. EVV compliance will be mandatory for Medicaid reimbursement of home visits. 

Summary of Key Dates

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 4.1) is available here. 

La versión 4.1 del Manual de CHW en español ya está disponible aquí.

Important Forms:

CHW Prior Authorization Form

CHW Certificate of Medical Necessity

PA Form Instructions

For additional information, please contact: 
EOHHS Provider Services: riproviderservices@gainwelltechnologies.com