Mary Ann Woodruff, MD, FAAP & Rachel Lettieri, LCSW
We invite you to read this recently released brief, A Pathway for Sustaining Community Health Workers in Pediatric Primary Care in Washington prepared by Liz Arjun at Health Management Associates, at the request of Zero to Three for the Pediatrics Supporting Parents Grant (PSP).
Pediatrics Northwest and WCAAP have partnered as Pierce: First Year Families since 2022 in this grant centered in 5 communities across the nation. The vision: Pediatrics Supporting Parents (PSP) seeks to transform pediatric well-child visits to strengthen early relational health and create lasting change that helps children succeed and families to flourish. Key to our work in PSP is the creation of teams of care at the medical home, central to this- Community Health Workers.
We are now at a critical juncture in Washington, the very existence of Community Health Workers in primary care at risk, vulnerable.
ABOUT COMMUNITY HEALTH WORKERS IN PRIMARY CARE
Community Health Workers in primary care are indispensable, the relational peer support that families themselves want, the ‘connective tissue’ of a functioning medical system. Paul Farmer, MD, founder of Partners in Health demonstrated again and again how Community Health Workers, community members with lived experience, are key to healing and prevention efforts through accompaniment with those they serve.
Paul Farmer defined accompaniment as a commitment to “walk alongside” those in need, fostering solidarity and partnership by going on a journey with them, supporting them, and sticking with a task until it’s deemed complete by the person being accompanied, not the helper. It emphasizes the importance of presence, empathy, and sustained commitment to patients, families, and communities, treating the whole person and their surrounding systems.
From CHW Pilot to CHWs Billing Under Licensed Provider in Primary Care
Our own experience in WA state echoes Farmer’s vision. Many pediatric primary care practices said a big yes over 3 years ago to be part of the groundbreaking CHW Pilot in primary care in WA state from Jan 1, 2023 to June 30, 2025. WCAAP leadership was pivotal to the creation of this pilot, having elevated the voices of family partners to legislative action.
This pilot program was highly effective and in 2023, the Legislature directed the Health Care Authority (HCA) to draw up a State Plan Amendment that would allow Medicaid to pay clinics for the services of Community Health Workers. As a result of HCA’s implementation of that legislative directive, clinics, as of July 1, 2025, can now bill Medicaid for services provided by CHWs to kids on Apple Health, under a licensed provider.
THE CONCERN
Here’s the howevers…
The Medicaid CHW billing codes: Requirement that a 60 min threshold of service by the CHW for a patient in a calendar month be reached in order to drop the charge. It is understood that the implementation of the billing codes is not meant to fully cover the salaries of the CHWs, yet this 60 min threshold means relatively few charges will be dropped given that CHWs often meet with families for brief amounts of time.
Commercial insurers: Reimbursement opportunities by commercial/private insurance plans for CHW services are limited and we are unaware of any paying on the CHW Billing code at this juncture.
Increased screening rates: WCAAP advocacy was pivotal in securing sequential rate increases for developmental, perinatal mood and anxiety disorder screening and mental health screening. The increased rates went into effect January 1, 2025 and starting July 1, 2025, in order to receive payment, pediatric and family medicine clinicians were required to apply a U1 or U2 modifier to each screening in order to receive payment, and document any referrals made in response the screening.
HCA sent a notification recently that the increases will continue to be paid through December 31, 2025 but will revert to prior 2024 levels January 1, 2026 due to state budget constraints.
POTENTIAL SOLUTIONS
Commercial and Private Insurers
HCA, OIC, DOH, private/commercial health plans, the Association of Washington Health Plans, HCA grantees, and other interested partners should collaborate to understand the value of providing CHW services to the overall pediatric population and identify a path forward. Data from the CHW Pilot demonstrates the need for CHW support regardless of insurance.
One such option could be to explore an assessment of all health plans in the state to fund CHW services in primary care, similar to how Washington’s Partnership Access Line is funded. Similar to the utilization of the PAL line benefit expanding to assist primary care for any client in the age range specified, CHW support could be made available under this assessment for any client seen in pediatric primary care.
CHW Billing Code Expansion
Exploring with HCA opening CPT codes designated for CHWs billing under the licensed provider that offer incremental time billing- ie threshold for dropping a charge of say, 15, 30 or 45 minutes. California and Oregon allow for a combination of HCPCS and CPT codes for CHW billing
Quality or Value Based Payment
HCA, Apple Health, MCOs, and other interested partners should explore experiences from other states that have taken this approach to improving the quality of care children receive and how to pay for overall health outcomes through value-based payment arrangements.
Accountable Communities of Health Funding
Accountable Communities of Health (ACH) each have their own approach to building care coordination hubs and a CHW network in their region. HCA could provide more statewide guidance about how different funding mechanisms available to support CHWs in a region can be combined. These efforts should include information about experiences and best practices from other states.
Restoration of Enhanced Screening Rates
Restoring the second phase (2025) of the rate enhancement for behavioral health screenings approved by the legislature
Promoting how the new CHW benefit can maximize opportunities to not only complete screenings but to connect kids and families to desired services. The additional revenue from this attention to screening can be used to support the salary of CHWs in primary care.
There is evidence that shows that developmental screening rates are increased and connections to services are much improved with CHW support for these processes.
IN SUMMARY
Coalition building is key to the hoped for success:
- Maintaining the current Community Health Workers in primary care from the pilot
- Creating a pathway for other pediatric primary care practices and to implement Community Health Worker teams
Community Health Workers are essential team members in primary care, advancing whole child and family care at the primary care medical home. They are able to decrease the friction people experience in being connected to resources and care, the antidote to lists of phone numbers, fingers crossed. Families can expect from the start to know who their Community Health Worker is. It’s a dream beginning to come true.
In future Developments we will continue to provide updates about Community Health Workers in pediatric primary care. We look forward to hearing from you.