Pennsylvania Medicaid has added Community Health Worker (CHW) services as a covered preventive benefit under the Medical Assistance (MA) program, effective January 01, 2026. The benefit is designed to support members with chronic conditions by reinforcing care plans and helping address barriers to care between doctor visits. CHWs became eligible to enroll in the MA program beginning April 18, 2026, to provide these services to qualifying members.

Coverage and Referral Requirements

Coverage is limited to three CHW visits per member per year. These visits must be recommended and billed by a Pennsylvania MA-enrolled physician, physician assistant, certified registered nurse practitioner (CRNP), or certified nurse midwife (CNM). All referrals must be documented in the medical record and included in the member's care plan. CHW services must be delivered by a Pennsylvania Certified Community Health Worker who is at least 18 years old.

Services that CHWs may provide include health education to support self-management of chronic conditions, help scheduling follow-up appointments, screening for health-related social needs, support connecting members with community resources and government programs, and individual advocacy to help patients follow their care plans.

CHW services do not cover case or care management, transportation or travel time, housing or employment services, childcare or respite care, medication or equipment delivery, interpreter services, exercise programs, missed visits, duplicate services, or services for non-Medicaid members.

Documentation Requirements

Each CHW visit must be documented in the medical record and must include the date, time, duration, location, and modality of the visit. Documentation must also cover appointment scheduling assistance if provided, the patient's understanding of their condition and self-management plan, screening results, resource navigation support given, disease-specific education delivered, educational materials provided, medication adherence support if applicable, and any community or resource recommendations made.

Billing

CHW services are billed using procedure code 98960 with modifier U2, in 30-minute increments, at a reimbursement rate of $25 per unit. Services are limited to three units per member per year.

For Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), CHW services are reimbursed outside of the Prospective Payment System (PPS) based on plan-negotiated rates. If CHW is the only service provided that day, providers should bill 98960-U2. If other services are also provided on the same day, providers should bill T1015 to receive the PPS rate.

For questions, providers can connect through 24/7 chat in the UnitedHealthcare Provider Portal at https://secure.uhcprovider.com/.