Thanks to outstanding partnership, along with valuable funder support over the past decade, Minnesota is recognized for key CHW field-building achievements. Our efforts are all about achieving health equity; improving health care quality, cultural competence and cost-effectiveness; and building individual and community capacity for better health.
Minnesota’s CHW Coverage Legislation: History and Lessons for the Future
In 2007, Minnesota Community Health Workers (CHW) and allies achieved a major policy milestone with the successful passage of CHW coverage legislation. Minnesota became one of the first states to obtain Medicaid payment for specific services provided by trained and trusted CHWs (Minn State Statutes 256B.0625, sub 49).
Learning about the birth and passage of this landmark bill as well as its implementation and results is important to understanding how we can continue to effectively advocate going forward. Building on our successes and addressing our challenges, we will create a strong and sustainable CHW field that advances health equity.
Developed by the Minnesota CHW Policy Council—precursor to the Minnesota CHW Alliance —the statute includes these main components:
- Minnesota Health Care Programs (MinnesotaCare and Medical Assistance, Minnesota’s name for Medicaid) covers care coordination and patient education services provided by CHWs who earn an educational certificate from an accredited Minnesota post-secondary school that offers the statewide standardized CHW curriculum developed at Minnesota State (formerly Minnesota State Colleges and Universities) and managed by the Alliance (as well as CHWs meeting the grandmothering provision –see below).
- CHWs must work under the supervision of an MA-enrolled physician, registered nurse, advanced practice nurse, dentist or certified public health nurse working in a unit of government. In 2009, the statute was amended to add mental health professionals to the list of authorized supervisors for billing purposes.
- Care coordination and patient education services include but are not limited to services relating to oral health and dental care.
Keys to Success
CHW Education. Our curriculum is the nation’s first statewide standardized CHW educational program based in higher education with credits that help build an educational and career pathway. It is based on the CHW scope of practice, a set of recognized skills and competencies that define this health equity profession. Foundational education is a key prerequisite for CHW coverage because payers need quality assurance and accountability for CHW performance. That is why the CHW certificate is a key component of the legislation along with supervision by specific provider types. In Minnesota, CHWs apply their unique strengths and training to make a difference as members of teams in a variety of settings.
Leadership, Strategy and Expertise. A successful legislative campaign requires planning, outreach, research, education and coalition building. The leadership of the Minnesota CHW Policy Council teamed up with the Saint Paul consulting firm of Health Advocates to design and implement this strategic advocacy effort powered by key support from CHWs and their allies.
Legislative Champions. The bill was sponsored by Representative Erin Murphy, who is now a member of the Minnesota Senate. With a passion for health policy and commitment to community health informed by her background in nursing, her leadership and support were critical. As the legislative session unfolded in the spring of 2007, this bill was wrapped into the Omnibus Health and Human Services bill under the guidance of Senator Linda Berglin. This package was passed and signed into law.
CHW Stories and Data. In-person meetings between CHWs and key committee members were instrumental in gaining legislative support. CHWs shared their stories first-hand with their lawmakers to help them understand their role and impacts in bridging gaps, preventing disease, lowering cost and improving outcomes in marginalized communities. Research results and documented return on investment (ROI) provided evidence of the field’s effectiveness. With growing recognition of social determinants of health, advocates described how CHWs address Minnesota’s health inequities.
Cost-neutral Fiscal Note. Legislative committees request fiscal notes to help them determine the likely fiscal impact of proposed legislation. They are typically prepared by the state agency most familiar with the bill. The fiscal note for the CHW coverage legislation concluded the bill was cost-neutral and projected that implementation would deliver modest cost savings to the State of Minnesota. This favorable fiscal review helped garner support.
Implementation and Results
Care Coordination. While this important CHW function is approved in statute, the Minnesota Department of Human Services (DHS), our state’s Medicaid agency, did not seek federal authority from the Centers for Medicare and Medicaid Services (CMS) to cover this service. As a result, CHW employers are not paid by DHS or by managed care plans for care coordination services.
Patient Education. DHS sought and obtained federal approval to cover this CHW service. In the Provider Manual, DHS outlined billing codes and guidelines. However, daily and monthly hourly limits for patient education services were instituted out of concerns about overutilization. Although the Alliance and allies have worked together with DHS to modify some of the guidelines, the limits have not been eliminated though it appears CHW services are underutilized across the state. In addition, CHW employers report that payment rates established by DHS are not sufficient to fully cover patient education services.
Grandmothering. Within the statutory time corridor (prior to January 1, 2010), CHWs with at least five years of supervised experience under a clinician enrolled under MA qualified for a certificate. A total of 63 CHWs were awarded certificates.
Billing Education and Improvements. Providing CHW employer education, offering technical assistance and fostering shared trouble-shooting and problem solving have contributed to improved claims submission and payment experience with DHS and health plans. Expanded efforts are needed.
The implementation of Minnesota’s CHW coverage legislation was an historic and important step forward in our state and the nation. Since that time, exciting progress has been made at the state and national levels. There is greater recognition of the field and its benefits at a time when COVID-19 has tragically exposed the deep and persistent health inequities that continue to divide our country.
The goal is to ensure that CHWs are part of the solution and can fully contribute to the health of Minnesota’s communities. The full scope of CHW services need to be integrated into the mainstream of our state’s health care, public health, mental health and oral health systems. Sustainable funding mechanisms are vital. Lessons learned from past successes (the power of leaders, coalitions, and CHW voices) will inform future advocacy by CHWs, members of the Alliance, and our allies. This work is driven by CHW leadership with our commitment to the value “Nothing about us without us.”
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