Community Health Worker Access Act

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—

(A) in subparagraph (II), by striking subsection (lll)(3)) and all that follows and inserting subsection (lll)(3));;

(B) in subparagraph (JJ), by inserting and after the semicolon at the end; and

(C) by adding at the end the following new subparagraph:

(KK) community health services (as defined in subsection (nnn)(1)) furnished on or after January 1, 2025;

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

The term community health services means the services described in subparagraph (B) that are furnished—

(i) by a community health agency (as defined in paragraph (2)); and

(ii) in accordance with an individual needs assessment that meets requirements established by the Secretary and is conducted under the supervision of an applicable provider; and

The services described in this subparagraph are the following:

Diagnostic, screening, and preventive services to prevent illness, disease, injury, or any other physical or mental health condition, reduce physical or mental disability, and restore an individual to the best possible functional level, including the following:

(I) Services described in section 1905(a)(13).

(II) Containment of infectious disease outbreaks, including providing in-language, culturally specific, and trusted support services, such as public health outreach.

(III) Direct provision of screenings and basic health services, as recommended by an applicable provider.

(IV) Provision of coaching and social support, such as support for individuals to obtain health care, support to reduce stress and social isolation, support for self-management of disease, and other support necessary for the prevention and management of health conditions.

(V) Care coordination and connection to preventive care services, including for chronic conditions, such as diabetes, asthma, chronic obstructive pulmonary disease, congestive heart disease, autoimmune disease, or behavioral health conditions.

(VI) Facilitation of transportation to needed services.

(VII) Promotion of healthy behaviors, such as physical activity and smoking cessation.

(VIII) Case management and linkage to resources that connect people with disabilities to assistive technology, home modifications, and other adaptations to increase their ability to live independently in the community.

(IX) Provision of support for health literacy and cross-cultural communication.

(X) Provision of culturally and linguistically appropriate health education.

(XI) Other services, as the Secretary determines appropriate to preserve and improve individual and public health.

Services to address social determinants of health, including the following:

(I) Assessment of individual and community needs and communicating identified needs to public health, health care, and social service agencies.

(II) Provision of outreach and education regarding health insurance, and other health and social service systems.

(III) Provision of education, assessment of needs, and social support through home visiting.

(IV) Provision of case management (as defined in section 1915(g)(2)) and linkage to resources to alleviate financial strain, including food, housing, child services, technology, educational services, employment services, and other services.

(V) Identification of underserved populations and referring them to appropriate health care agencies and community-based programs and organizations in order to increase access to quality health and social services and to streamline care, including serving as a liaison between individuals and communities and health and social service organizations.

For purposes of subparagraphs (A)(ii) and (B)(i)(III), the term applicable provider means—

(i) a physician (as defined in section 1861(r));

(ii) a physician assistant, a nurse practitioner; and a clinical nurse specialist (as such terms are defined in section 1861(aa)(5)); and

(iii) any other practitioner described in section 1842(b)(18)(C) that the Secretary determines appropriate.

The term community health agency means an entity, including a community-based organization, a nonprofit organization, an urban Indian organization, a community health worker network, a Federally qualified health center, a rural health clinic, a local or State public health department, an academic institution, a health care provider, and any other organization deemed appropriate by the Secretary, that meets requirements established by the Secretary, which may include the following requirements:

(A) The entity provides for the employment of health workers who share lived experiences with the community served and minimize barriers to employment, including formal educational requirements.

(B) The entity provides for market wage compensation and professional development and career advancement opportunities for health workers, as well as training on core competencies.

(C) The entity has established work practices and manageable caseloads that allow health workers to provide tailored, holistic, person-centered support.

(D) The entity ensures—

(i) the safety of health workers, in accordance with applicable fair labor laws;

(ii) the supervision, coaching, and evaluation of health workers, through the use of evidence-informed process and outcome indicators developed in consultation with community health workers, promotoras, and community health representatives (as such terms are defined in section 1903(cc)(4)); and

(iii) leadership and engagement of health workers in organization- and program-level decision making, including decision making related to the improvement of processes and outcomes.

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395 l (a)(1)) is amended—

(A) by striking and before (HH); and

(B) by inserting before the semicolon:, and (II) with respect to community health services under section 1861(s)(2)(KK), the amounts paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under a fee schedule established by the Secretary for such services.

The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended—

(A) by striking, and (13) and inserting (13); and

(B) by striking 1861(n).. and inserting 1861(n), and (14) such deductible shall not apply with respect to community health services (as defined in section 1861(nnn)(1))..

Notwithstanding section 1902(a)(1) (relating to statewideness), section 1902(a)(10)(B) (relating to comparability), and any other provision of this title that the Secretary determines is necessary to waive in order to implement this subsection, beginning January 1, 2025, a State, at its option as a State plan amendment, may provide for medical assistance for preventive services and services to address the social determinants of health furnished by a community health worker, promotora, or community health representative.

The Secretary shall issue guidance on the components that are necessary for a State plan amendment to receive approval under this subsection, including:

(A) Plans to recruit community health agencies for the provision of preventive services and services to address the social determinants of health that are furnished by a community health worker, promotora, or community health representative.

(B) Plans to make medical assistance available for each category of preventive services and services to address the social determinants of health.

(C) Plans to ensure that the preventive services furnished by community health workers, promotoras, or community health representatives under the amendment will respond to public health emergencies.

(D) Plans to minimize barriers to community health worker, promotora, or community health representative program participation in the State plan, such as by providing guidance and technical assistance on requirements for participation.

(E) Plans to coordinate with and build the capacity of community health worker networks within the state or region.

(F) Plans to address barriers to participation experienced by community health agencies that do not bill insurance for other services, such as community-based and nonprofit organizations, academic institutions, faith-based organizations, tribal organizations, or other organizations that employ community health workers, promotoras, or community health representatives, including by implementing a mechanism to reimburse such community health agencies for preventive services and services to address the social determinants of health.

Notwithstanding section 1905(b), for calendar quarters beginning on or after January 1, 2025, the Federal medical assistance percentage determined under such section for a State shall be increased by 6 percentage points with respect to amounts expended by the State for medical assistance for preventive services and services to address the social determinants of health furnished by a community health worker, promotora, or community health representative that is provided in accordance with a State plan amendment approved under this subsection or otherwise provided in accordance with the guidance issued under paragraph (2).

With respect to payments made to a territory for expenditures for medical assistance described in subparagraph (A), the portion of such payment that exceeds the amount that would have been paid without regard to the increase in the Federal medical assistance percentage under such subparagraph shall not be taken into account for purposes of applying payment limits under subsections (f) and (g) of section 1108.

In this subsection:

The term community health agency has the meaning given that term in section 1861(nnn).

The term community health representative means a frontline health worker who is a trusted member of a tribal community with a close understanding of the community, language, and traditions that enables the worker to serve as a liaison between health and social services and the community, facilitate access to services, and improve the quality and cultural competence of service delivery.

The term community health worker means a frontline health worker who is a trusted member of the community in which the worker serves or who has an unusually close understanding of the community served that enables the worker to build trusted relationships, serve as a liaison between health and social services and the community, facilitate access to services, and improve the quality and cultural competence of service delivery.

The term community health worker network means a statewide, regional, or local association or coalition with leadership and membership that is composed of at least 50 percent community health workers, promotoras, or community health representatives and whose activities include training, workforce development, mentoring, and other initiatives to support community health worker, promotora, and community health representative programs.

The term preventive services means services described in clause (i) of section 1861(nnn)(1)(B).

The term promotora means a trusted frontline worker who primarily works in Spanish-speaking communities and who shares lived experiences, language, and culture with the populations served that enables the worker to improve individual, family and community health outcomes by serving as a liaison between health and social services and the community, facilitating access to services, and improving the quality and cultural competence of service delivery.

The term services to address the social determinants of health means services described in clause (ii) of section 1861(nnn)(1)(B).