Pennsylvania Medicaid adds coverage for Community Health Worker services

Effective Jan. 1, 2026, Community Health Worker (CHW) services are a covered preventive benefit under the Medical Assistance (MA) program. These services support members with chronic conditions by reinforcing care plans and addressing barriers between visits.

CHWs may enroll in the MA program beginning April 18, 2026, to render services to eligible members.

By connecting patients to education and resources between visits, CHWs can help improve adherence, close gaps in care and support better health outcomes.

Coverage and referral requirements

Coverage is limited to 3 CHW visits per member per year that are recommended and billed by an MA-enrolled physician, physician assistant, certified registered nurse practitioner or certified nurse midwife.

Referrals must be documented in the medical record and included in the care plan. CHW services must be provided by a Pennsylvania Certified CHW who is 18 years or older.

Services may include:

• Health education to support condition self-management
• Help scheduling follow-ups
• Screening for health-related social needs
• Support connecting with community resources and government programs
• Individual advocacy to help patients follow care plans

CHW services do not include:

• Case/care management
• Transportation or travel time
• Housing or employment services
• Childcare or respite care
• Medication or equipment delivery
• Interpreter services
• Exercise programs
• Missed visits or duplicate services
• Services for non-Medicaid members

Documentation requirements

CHW visit documentation must include:

• Date, time, duration, location and modality
• Appointment scheduling assistance (if applicable)
• Patient understanding of condition and self-management
• Screening results
• Resource navigation support provided
• Disease-specific education delivered
• Educational materials provided
• Medication adherence support (if applicable)
• Community/resource recommendations

Billing

• Procedure code: 98960–U2
• Unit: 30-minute increments
• Reimbursement: $25 per unit
• Limited to 3 units per member per year

For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs):

• CHW services are reimbursed outside of PPS based on plan-negotiated rates
• If CHW is the only service provided that day, bill 98960–U2
• If other services are provided, bill T1015 to receive the PPS rate