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Reimbursable Services

Starting on January 1, 2014, in Illinois, Medicaid began to allow reimbursement for preventive services delivered by non-licensed providers including community health workers and peer educators, upon recommendation from a licensed Medicaid provider. The rule from the Centers of Medicare and Medicaid Services (CMS) states:

“Preventive services means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to:

  1. Prevent disease, disability, and other health conditions or their progression;
  2. Prolong life; and
  3. Promote physical and mental health and efficiency.”

Under the CMS rule, some examples of potentially reimbursable services include:

  • Prevention services
  • Care coordination and educational counseling
  • Home visits
  • Group health education, as long as Medicaid enrollees have some interaction with a licensed counselor
  • Science-informed parenting education

The traditional roles of peer advocates match quite well with community health worker roles reimbursable by Medicaid. As a result, peer advocates can add value to a care team wishing to achieve patient engagement across the care continuum – an important goal of HIV prevention and treatment.

Medicaid-Reimbursable Preventive Services Delivered by Peer AdvocatesMedicaid-Reimbursable Preventive Services Delivered by Community Health Workers
Testing for HIVProviding basic screening services
Referring and linking patients to medical care; conducting outreach to re-engage patients not regularly receiving careEnsuring that patients obtain necessary health care services
Providing orientation and counseling to new patientsProviding informal counseling and social support
Helping patients to navigate the health insurance and health care systems; addressing barriers to care access and retentionProviding cultural mediation between communities and health and human services systems
Providing health education focusing on treatment adherence at appropriate literacy levelAssisting with providing culturally appropriate health education

Peer advocates can assist at all five steps of the HIV Care Continuum — from the HIV diagnosis to the patient achieving viral suppression.

HIV Care Continuum infographic