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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:
- Prevent disease, disability, and other health conditions or their progression;
- Prolong life; and
- 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 Advocates | Medicaid-Reimbursable Preventive Services Delivered by Community Health Workers |
|---|---|
| Testing for HIV | Providing basic screening services |
| Referring and linking patients to medical care; conducting outreach to re-engage patients not regularly receiving care | Ensuring that patients obtain necessary health care services |
| Providing orientation and counseling to new patients | Providing informal counseling and social support |
| Helping patients to navigate the health insurance and health care systems; addressing barriers to care access and retention | Providing cultural mediation between communities and health and human services systems |
| Providing health education focusing on treatment adherence at appropriate literacy level | Assisting 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.
