New York Medicaid pays for qualifying CHW services through eligible supervising providers and institutions. The CHW does not independently enroll or bill under this benefit. Program leaders need to verify workforce preparation, member eligibility and overlapping services before payment. This guide connects those requirements with practical documentation, referral and software workflows. [1]
New York CHW quick facts
| Topic | New York guidance |
|---|---|
| Payment model | Eligible supervising provider or institution bills; CHW does not independently enroll. [1] |
| Standard preparation | 20 hours of C3-based training or 1,400 relevant hours in three years, plus basic HIPAA training. [1] |
| Covered service categories | Health advocacy, education and navigation, subject to eligibility. [1] |
| Expanded populations | Children, qualifying adults and other specified groups, beyond pregnancy alone. [1] |
| Supervision | Licensed, Medicaid-enrolled supervising provider. [1] |
| Code family | 98960, 98961 and 98962; exact modifiers and setting matter. [3] |
| Modifier order | Ordinary CHW: U1 then U3; violence prevention: U3 then U1. [3] |
| Clinic distinction | CHW-only FQHC/RHC service has separate billing instructions. [3] |
| Social Care Network overlap | SCN-related navigation has a specific nonduplication boundary. [1] |
| Current manual | eMedNY policy manual dated August 2025. [1,4] |
| Last reviewed | November 6, 2026 |
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What does a CHW do in New York?
The Medicaid framework describes health advocacy, education and navigation that support access, understanding and participant goals. A CHW's lived experience and community relationship are important parts of the role. Program duties can extend beyond the portion of work a particular payer covers. [1]
Employers should identify the community served, language needs, service area, referral relationships and supervisor. Explain escalation when a participant needs clinical care or a service outside the CHW's preparation. A role description should preserve community trust while setting clear responsibilities.
Is a course certificate the same as Medicaid eligibility?
No. A training completion award documents learning, while Medicaid eligibility involves the worker, participant, supervising provider, service and setting. Use the benefit's workforce criteria rather than treating any certificate as a universal billing authorization.
An onboarding checklist should distinguish training, experience verification, background review, assignment and payer readiness. Keep a worker's supporting evidence available to the responsible employer without confusing an internal approval with state provider enrollment.
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What preparation does the standard Medicaid pathway require?
The August 2025 manual specifies at least 20 hours of C3-based training or 1,400 hours of CHW experience in formal paid or volunteer roles within three years, plus basic HIPAA training. Violence-prevention services have additional conditions. [1]
Before counting experience, document dates, duties, hours and verification. Ask a training provider what the course covers and what evidence it issues. A short specialty workshop should not automatically be accepted as the entire foundational route.
Who is responsible for workforce verification?
The manual assigns the employer responsibility for verifying training and experience and completing background checking suitable for the population served. Keep the verification decision and its supporting evidence, rather than relying on a job title. [1]
A program director should know who checks readiness before a worker begins a particular service. A vendor can organize records, but it does not decide the state's requirements or remove the employer's review responsibility.
Which Medicaid members may qualify?
The August 2025 manual identifies these populations:
- Children younger than 21.
- Pregnant people and those up to 12 months after pregnancy ends, regardless of outcome.
- Adults with chronic conditions.
- People with justice-system involvement during the preceding 12 months.
- People with a housing, nutrition, transportation or interpersonal-safety need identified using the specified CMS screening tool.
- People exposed to community violence, with a related injury history, or at elevated risk of violent injury or retaliation.
A practitioner recommendation is also required. The broad population categories should not be treated as a substitute for the manual’s coverage and nonduplication conditions. [1]
Do not assume that membership in a broad population automatically satisfies every coverage condition. Verify the person's coverage, applicable need and other services before the contact. Record the actual eligibility basis without inventing a diagnosis to complete a form.
Who supervises and bills for CHW services?
New York's framework uses an eligible Medicaid-enrolled clinician, institution or other authorized billing entity. The CHW does not independently enroll and submit claims for these services. The supervising and billing roles must match the actual arrangement. [1]
For a community organization working with a clinical partner, agree on the referral, access to documentation, review and responsibility for claims. The existence of a partnership does not automatically make every community outreach activity payable.
How do Health Homes fit into the benefit?
New York added Health Homes to the eligible billing entities in 2025, with different fee-for-service and managed care implementation dates. That does not remove restrictions on duplicating care coordination already provided through another covered arrangement. [5]
The manual excludes CHW coverage while a member receives care coordination through a Health Home, CCO Health Home, CCBHC or Assertive Community Treatment program, and excludes members in institutional settings. A Health Home can provide CHW services before or after the person receives its other care-management services, rather than during enrollment in the Health Home program. Distinguish an organization’s ability to bill from a particular member’s eligibility at that time. Policy manual, pages 6 to 7.
For a fictional member being considered for CHW education, check the existing care-management relationship before scheduling payable work. If the member is actively receiving excluded care coordination, a different label on a similar contact does not remove the restriction. Preserve the actual handoff and identify which organization owns follow-up.
How do Social Care Networks affect navigation?
The current manual says members receiving Social Care Network services are not eligible for CHW health navigation. It directs screening, navigation and referral for managed-care social services to the regional SCN. This is specifically a health-navigation boundary; do not automatically extend it to every other CHW service without checking the actual coverage conditions. [1]
A shared intake should help staff identify which organization owns the next step. Do not send duplicate tasks to several partners and then count each as a separately payable service. Participant follow-up should remain clear even when funding responsibility differs.
What is different about community violence prevention?
The manual sets additional experience, training, approval and continuing education conditions for CHWs providing community violence prevention. The ordinary training-or-experience pathway should not be treated as sufficient for that specialty service. [1]
The specialty pathway requires at least six months of full-time-equivalent community violence-prevention or high-risk or justice-involved youth-development experience during the past three years. Employment, volunteering or an internship can supply that experience. It also requires violence-prevention training through an approved entity, Office of Gun Violence Prevention approval and at least four hours of annual continuing education in the field. Keep that specialty evidence separate from ordinary CHW preparation. Policy manual, sections 11.1 to 11.2.
A Health Home billing for violence-prevention services must meet both sections’ training requirements. The employer should confirm the individual’s actual specialty approval and yearly learning before assignment. General lived experience or a job title does not replace those documented conditions.
Which codes and modifier order should billing teams review?
New York's clinic guidance uses 98960, 98961 and 98962. It specifies U1 followed by U3 for ordinary CHW services, and U3 followed by U1 for community violence prevention. The order is part of the instruction. [3]
How do units and annual allowances work?
The current manual’s code table uses 30-minute units. It states a minimum of 16 and maximum of 37 minutes for one unit and lists annual allowances of 12 units for adults and 24 for members younger than 21. The individual code is 98960, the two-to-four-member group code is 98961 and the five-to-eight-member group code is 98962. These are annual allowances, not daily limits copied from another state. Policy manual, pages 12 to 14.
Health Homes have separate fee-for-service rate codes, 1886 through 1891, distinguishing ordinary CHW work, violence prevention and group size. Managed-care claims by those entities follow the manual’s CPT instructions and the plan’s coverage and billing guidance. Confirm the current applicable fee schedule instead of assuming one dollar rate fits every billing entity. Policy manual, pages 13 to 14 and section 11.4.
A claim for an adult age 21 or older must identify the qualifying chronic condition, social need or risk criterion through the appropriate diagnosis code. Preserve the actual assessment and service evidence rather than inventing a code to satisfy a form. Policy manual, section 9.
How are CHW-only FQHC and RHC services handled?
The state's October 2024 update describes a separate payment in place of the ordinary PPS rate when the CHW service is the only service. It directs the specified ordered ambulatory claim route and distinguishes a comprehensive encounter with other medically necessary services. [3]
The current manual expressly says CHW services must be provided on-site at the FQHC and that off-site CHW services are not reimbursable under that instruction. It also prohibits an APG claim when CHW is the only service, including for FQHCs that have opted into APGs. Clinic teams should distinguish that circumstance from a comprehensive encounter with other medically necessary care. Policy manual, section 8.2.
Can interpretation or indirect work be billed as CHW time?
The manual excludes language interpretation from covered CHW services and gives a separate interpretation-payment arrangement through the licensed billing provider. It also excludes time without direct member engagement. For work involving a parent or legal guardian for a member younger than 21, the member must be present and the service must directly benefit that member under the recommendation. A bilingual worker’s presence or a staff-only referral discussion does not automatically establish a payable CHW encounter. Policy manual, pages 9 to 10 and section 10.
What should New York CHW documentation show?
The manual requires a record accessible to the supervising provider, including the recommendation and service date, time, duration and nature of the service. Supporting content should explain the time spent. [1]
For operational continuity, make the participant's goal, response, referral outcome and next owner easy to find. Distinguish an offered resource from an accepted referral, scheduled appointment and confirmed service. Preserve corrections and unresolved barriers.
How should program leads select CHW training?
Start with the service and population the worker will support. Review curriculum, learning methods, assessment, language, cost and completion evidence. If a program advertises certification, identify the issuer and what the award actually establishes.
Compare the training with employer and payer conditions before enrollment. Create a plan for specialty learning and ongoing supervision rather than assuming one course prepares a worker for every population and service.
What should New York CHW software demonstrate?
Use a fictional community organization and supervising partner. Verify worker preparation, member eligibility, recommendation, contact documentation, referral follow-up and report production. Include a participant receiving overlapping navigation services so the team can test the handoff.
Explore community health workflows with Smores Health using your forms and reporting definitions. Ask which capabilities exist today, which need configuration and what remains a gap. Claims submission is not live in Smores Health.
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Which reports should directors use?
Separate people served, contacts, referrals and confirmed outcomes. Keep general CHW services, violence prevention and other navigation arrangements identifiable. A sent referral should not automatically be counted as an outcome.
Trace a total to the underlying records and test a corrected note, group contact and unresolved need. Confirm the reporting period, who can export results and how a previously submitted report can be reproduced.
Frequently asked questions
Does the CHW independently bill New York Medicaid?
No. The benefit uses eligible supervising providers or institutions. [1]
Is one course certificate enough to establish payment?
No. Worker preparation is one part of a larger coverage and provider arrangement.
Does modifier order matter?
Yes. New York specifies different consecutive order for ordinary CHW and community violence prevention services. [3]
Can a CHW-only clinic service always use the usual PPS claim?
No. The state describes a separate billing route for that circumstance. [3]
What should a software demonstration include?
Ask for a complete participant workflow with workforce evidence, supervising review, referral status and traceable reporting.
Build a clearer New York CHW service record
Bring a workforce checklist, blank encounter form and one required report to Smores Health. Book a program walkthrough to evaluate documentation and follow-up for your New York team. Request pricing for a clear implementation scope.
Sources
[1] eMedNY, CHW policy manual, August 2025. https://www.emedny.org/ProviderManuals/CommunityHealth/PDFS/CHW_Policy_Manual.pdf
[3] NYSDOH, October 2024 Medicaid Update, FQHC/RHC CHW billing. https://healthweb-back.health.ny.gov/health_care/medicaid/program/update/2024/no11_2024-10.htm
[4] eMedNY, current CHW manual and update hub. https://www.emedny.org/ProviderManuals/CommunityHealth/
[5] NYSDOH, December 2024 Medicaid Update, Health Home eligibility. https://healthweb-back.health.ny.gov/health_care/medicaid/program/update/2024/no13_2024-12.htm