OHCA Policies and Rules

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317:30-5-1162. Community Health Services

[Issued 01-31-25]

(a) Overview. Community Health Services are a preventive health service to prevent disease, disability and other health conditions or their progression; to prolong life; and/or to promote physical and mental health and efficiency. Community Health Services are furnished by community health workers (CHW). CHWs are trusted members of a community who help address chronic conditions, preventive health care needs, and health-related social needs.

(b) Covered Services. Communtiy Health Services include:

(1) Health education and coaching, in individual or group settings, consistent with established or recognized healthcare standards, to promote beneficiaries’ awareness of and engagement in health care and other related services as well as chronic disease self-management methods; including care planning, setting goals, and creating action plans to address barriers to engaging in care and/or self-management of chronic conditions;

(2) Screening and assessment to uncover the need for services;

(3) Health system navigation and health-related social resource coordination to assist beneficiaries with access to appropriate health care and other related community resources; care coordination services include engaging with beneficiaries and interdisciplinary care teams as a part of a team-based, person-centered approach to support and advocate for physical and mental health including during time-limited episodes of instability.

(c) Member Eligibility. In order to receive CHW services, a beneficiary must have services ordered by a physician or other licensed practitioner and must have at least one of the following:

(1) Diagnosis of one or more chronic health conditions including behavioral health conditions

(2) Self-reported/suspected or documented unmet health-related social need

(3) Received a screening

(4) Pregnancy

(d) Provider Eligibility.  In order to provide CHW services, an individual shall, in addition to the requirements set forth in 317:30-5-1152:

(1) Be at least eighteen (18) years of age, a legal United States resident, and a resident of Oklahoma

(2) Be contracted with the State Medicaid Agency or its designee

(3) Pass a background check

(4) Obtain a certificate of completion of a C3 core competency-based Community Health Worker training offered by the Oklahoma State Department of Health, Tulsa City County Health Department, and/or Oklahoma City County Health Department; or have 2,000 documented hours of paid, volunteer, or lived experience

(5) Have lived experience that aligns with the community being served

(6) Work and bill under a licensed provider

(e) Limitations. The following limits exist for community health services.

(1) Individuals may not receive more than 2 hours or 4 units per member per day.

(2) Monthly service limits are not to exceed 12 hours or 24 units.

(3) Hour limits are constant, regardless of whether services are administered in an individual or group setting.

(4) A visit may consist of multiple units of service on the same date; the time for units of service is added together and rounded up only once per visit.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.