Leveraging Medicaid to Support Community Health Workers and Address Health-Related Social Needs

JENNIFER JEAN-PIERRE:
Welcome to another Public Health Conversation where we delve into the intricacies of public health and its impact. I am your host, Jennifer Jean-Pierre, Director of Content Development at ASTHO. Today, we're going to discuss leveraging Medicaid authorities for community health worker initiatives. I am joined by Diana Crumley. The associate director of delivery system reform at the center for healthcare strategies.

DIANA CRUMLEY:
Yeah, my name is Diana Crumley. If you're not familiar with the Center for Healthcare Strategies, we're a policy and implementation partner dedicated almost exclusively to Medicaid.

And we essentially do a lot of what I'm doing here today, translating Medicaid to a wider audience. And we have a wide variety of partnerships with us though actually thinking about Medicaid and public health partnerships specifically.

JEAN-PIERRE:
And how long have you been doing this type of work? How long have you been in this particular role?

CRUMLEY:
Yeah, so I've been in my role at the Center for Healthcare Strategies for about seven years now. And in that capacity, I've thought about community health workers, health related social needs primary care, and specifically primary care transformation. And really, just thinking about all the different levers that state Medicaid agencies have to advance more whole person equitable care for their members.

In my past life, I worked for the Texas Health and Human Services Commission and that particular agency had oversight authority of not only Medicaid but also public health agencies as well. And so interfaced with my public health partners from time to time in that capacity as well.

JEAN-PIERRE:
Okay. So let's really dive in. We're speaking on Medicaid authorities and cross agencies opportunities to address health related social needs and finance community health worker led services. So my question is, what trends have you seen as it relates to community health worker services and Medicaid?

CRUMLEY:
Yeah, I think really reflecting over the past decade, Medicaid has increasingly seen community health workers as a really essential and integral workforce really an important workforce that connects both health and social care. And really builds trust with communities and particularly communities that have been marginalized.

So over the past decade, states have thought about what does value mean? What contributes to good health? How do you build trust with communities? How do you meet an individual's basic needs so they can really focus on health care. We've also, increasingly heard about health equity and really centering health equity in our different priorities and strategies.

Crumley: And community health workers essentially relates to all those different priorities that are top of mind for state Medicaid agencies. We saw a little bit of an uptick around 2014 of. Some states thinking about actual Medicaid coverage of community health worker services, and I think we're beginning to see another uptick now after COVID 19 grant funds are drying up, and states are really trying to strategically think about how they can build upon the good work that already has been built on their states, in their state, and really think about Medicaid as a part of potential sustainable financing vehicle.

One of many but nonetheless a very important way to really strengthen community health workers and really increase access to that integral service.

JEAN-PIERRE:
Thank you. Diana, what health-related social needs or HRS N services. Are part of the centers for Medicare and Medicaid services, section 1115 demonstration opportunities.

CRUMLEY:
So first I'll talk a little bit about what a section 1115 demonstration looks like. Is just in case folks aren't familiar, and that's essentially a way for state Medicaid agencies to flex standard rules around Medicaid in order to Test innovative models and each administration often comes up with ideas to potentially test via a section 1115 demonstration opportunity and most recently, essentially, the centers for Medicare and Medicaid services really responded to immense state interest in health related social needs and outlined a variety of services that could be covered under a section 1115 demonstration opportunity. And essentially those are in three broad categories, nutrition supports, housing supports, and health related social needs case management. Often that health related social needs case management is performed by community health workers and other, folks in the community.

Within the broad categories of housing and nutrition services, for example, nutrition services includes things like pantry stocking medically tailored meals, food prescriptions, things that we've been hearing over the past, five, six years as being really a potentially innovative way to meet And address food insecurity.

The housing suite is also getting some interest because essentially CMS has loosened some common restrictions around using Medicaid funding to provide room and board. And I think the most notable which, states. Or your audience may have heard about is potentially using Medicaid to cover six months of transitional rent for, a small subset of the population that may be transitioning from a nursing facility or perhaps transitioning from homelessness within a particular state.

JEAN-PIERRE:
Thank you. Diana let's change gears just for a minute. Can you explain and share the benefits of F map or the federal medical assistance percentage?

CRUMLEY:
Yeah, so FMAP is Federal Medical Assistance Percentage. You may also hear about Federal Financial Participation.

And essentially these acronyms Speak to the unique role or the unique structure of Medicaid as a state federal partnership. The feds pay part of it and the states pay part of it. And essentially what's happening with whenever you cover something through Medicaid is that you are drawing down those federal funds at a particular time.

FMAP, Federal Medical Assistance Percentage. It can be higher in some states and in some states it's much closer to 50 percent. Essentially, when things are covered by Medicaid, that allows state funds to go further. Many community health worker service programs, they might have federal funding sources, but they also might be locally.

Funded or funded only by state general fund dollars, and so FMAP and FFP, federal financial participation, is essentially is a shorthand for saying you're drawing down federal funds, federal matching funds for those Medicaid services.

However states leveraging 1115 waivers to finance community health worker services. States have done this traditionally in different ways. I spoke most recently about the health-related social needs demonstration opportunity. And in that context, essentially, the framework has two details coverage for health related social needs services. So allowing states to cover those nutrition, housing, case management services, and then something called health related social needs infrastructure.

And that health-related social needs infrastructure funding speaks to the need to build social care. capacity to actually engage with Medicaid. It also speaks to the need for workforce development, and for example, one of the the potential areas where you can think about workforce development dollars and spending those health related social needs infrastructure dollars is on community health worker certification, or perhaps on trauma informed training or cultural competency training.

Things that come up in the context of trying to stand up these new health related social needs services and doing them well. So there, that is definitely a conversation that can happen in states because of these health related social needs infrastructure dollars. There's also a number of states over the years, and I believe the National Academy of State Health Policy has estimated five or six states that have specifically used 1115 waiver funding to fund community health workers in different ways.

JEAN-PIERRE:
So we're definitely playing the acronym game at this point, but I know there are several states that have leveraged state plan amendments spas to cover community health worker services. Could you speak a little bit more on that?

CRUMLEY:
Yeah. So here's another acronym SPA. It sounds nice. It sounds luxurious. But essentially it's a shorthand for making something a Medicaid benefit.

This is another example of Medicaid being a state federal partnership. Essentially, the state has something called a state plan. If you've ever downloaded a Medicaid state plan in its entirety, you will see pages and pages upon pages. They are essentially 2, 000 some pages long. But the SPAs themselves, the state plan amendments, are often just, slight modifications to that state plan. So essentially the state says, "hey federal government, we now want to provide community health worker services." And so states like Louisiana, California North Dakota have used state plan amendments to essentially say, this is what we're covering. And, This is how we're going to determine whether or not it can be covered by Medicaid, by someone that's enrolled in Medicaid as a provider.

And that is a pretty significant trend that we're seeing now. After COVID 19 a number of states have essentially submitted and received approval of state plan amendments. And those are essentially making community health worker. services a covered benefit under Medicaid. It has also coincided with a really deep interest in doula services as well.

So in many states you will see both the state thinking about community health worker services and doula services within the same year or the same couple of years.

JEAN-PIERRE:
Well, since we're speaking about spas, the state plan amendments. Can you just tell us a little bit more about the pros and cons and how they compare to the 1115 waiver.

CRUMLEY:
Yeah, definitely. So in terms of a state plan amendment those are generally, something that happened, many times a year. States will have state plan amendments going through different processing elements and requests for information throughout the year. And those are commonplace.

They have a shorter approval timeframe pretty simple administrative process. Of course, actually having these conversations in states and determining what The state plan benefit would look like can come with its own unique timelines, but the actual process of CMS approval is much simpler for 1115 demonstrations.

You and your audience may have encountered state Medicaid agencies that are very cautious to. Take on a new 1115 demonstration. Those are pretty big events in states. Often there is already some kind of 1115 demonstration that is approved at any given point of time. And those can be multiple year engagements in terms of drafting a proposal for that particular 1115 demonstration, and then also navigating all the various steps of CMS approval and negotiation. So again, those are lengthy documents and not necessarily a simple undertaking. There are pretty significant events in states when a 1115 demonstration goes through the different steps of approval.

JEAN-PIERRE:
So, are there any other financing mechanisms that can be used to cover health related social needs services? And or community health worker services.

CRUMLEY:
Yes. There certainly is a role here for blended and braided funding. And so to the extent that there are non Medicaid vehicles, that is an option.

In terms of, Medicaid or, Medicare coverage there are different ways that states can essentially think about community health worker services. I will say that historically, states have really thought about the role of managed care organizations, as well as Providers and value-based payment arrangements, and that's just a fancy way of saying providers are paid to improve quality in some capacity and not just, pay for it service by service. There's been a real push to essentially use those different levers that states have to increase the use of community health worker services. For example, you will see managed care contracts and saying managed care organization, please tell us how you will increase the use of community health worker services throughout the year.

Perhaps there will be a ratio, perhaps there's just a reporting requirement, but those are often embedded in contracts with managed care organizations. And for awareness, most states have managed care. There's a subset that do not have managed care organizations, but that is very common. Similarly, there's been a real focus on finding new and better ways to pay for care.

And so you will see, primary care payment models, for example, really thinking about, what is this payment model trying to achieve? And that's often tied to general ideas about improving care delivery and specifically team based care integrating community health workers.

Recently, Medicare has also turned heads and, Medicaid is different than Medicare. Medicare is completely federal. Medicaid has that federal state partnership. But many folks have been looking to Medicare fee schedule changes. And essentially that will also mobilize, specific funding for community health integration and partnerships with community health workers in that context.

JEAN-PIERRE:
Well, we've made it to the end and I have just one last question. And it really focuses on partnership. So how can state and territorial public health agencies support their state Medicaid agencies to develop policies, programs that address individuals health-related social needs.

CRUMLEY:
Yeah, and I think this is something that, it's been lovely to partner with ASTHO, among others, to really think about, that, that partnership and how to support that partnership.

And I think, first and foremost, often Medicaid is picking up the baton here, right? Public health has done so much good work as it relates to community health worker investments thinking about certification, thinking about growing these different grant funded initiatives in states. And really being intentional about working with Medicaid on how to structure community health worker services as a benefit or perhaps as a pilot program or some other initiative funded by the state through different ways. Thinking of ways that you can really elevate what has been done before and how can Medicaid plug into that conversation to really identify how they can be not duplicative, but also build upon the work that has already been done by public health. And particularly, public health. can think about, essentially letting Medicaid know what to be prepared for as they navigate all these different discussions about bringing community health worker services into the Medicaid world, which walks and talks very differently than public health.

And so having those conversations up front, I think will be particularly influential to really think about how implementation of the community health worker services benefit or pilot program, whatever is being implemented. How can it go? And, anticipate potential implementation issues.

JEAN-PIERRE:
Diana, I have really appreciated this discussion. So thank you for joining our public health conversation. Our listeners now have a better understanding of 1115 waivers, a better grasp of the partnership with Medicaid. And of course, all of the acronyms that we've been throwing around in this episode. But before we close out, Is there anything that you would want our state and territorial public health agencies to know about partnering, collaborating with state Medicaid agencies?

CRUMLEY:
I think this has been a lovely discussion, and I know that my colleagues have been elevating different written resources on community health worker services and what Medicaid is doing. Also, really closely monitoring developments on health-related social needs. The Center for Healthcare Strategies is always a useful thought partner for those discussions.

And we look forward to really learning alongside all the different states that we work with in this capacity.

JEAN-PIERRE:
Thank you for listening to an ASTO Public Health Conversation. Please find additional 1115 waiver I'm community health worker services, resources. In the show notes @astho.org. Thank you for listening. And have a great day.