The Medicare Gap: Why New Mexico’s CHW Standing Order Doesn’t Cover Many of the People CHWs Serve
New Mexico’s standing order lets certified Community Health Workers and Community Health Representatives (CHW/Rs) bill Medicaid on their own — but not for clients who also have Medicare. For those clients, Medicare must be billed first, and Medicare plays by very different rules.
Picture a CHR visiting a 72-year-old grandmother on her reservation. She has diabetes, no reliable ride to her clinic, and a stack of mail she can’t sort through. The CHR checks her blood pressure, helps her reschedule a missed appointment, and teaches her how to read her glucose log. That is exactly the kind of work the standing order was built to pay for.
But if she has Medicare as her primary insurance and Medicaid as secondary, that visit may not be billable under the standing order at all. Many CHW/Rs don’t find this out until claims start coming back denied. This article explains why it happens and what programs can do about it.
What the standing order does
New Mexico was the first state to give CHW/Rs a statewide standing order, so they don’t need a new physician order every time they see a Medicaid member. The order is signed by the Chief Medical Officer of the Health Care Authority’s Medical Assistance Division (HCA/MAD). That signature stands in for a clinician’s order, which is what lets a certified CHW/R bill independently of a clinic or physician group.
Under the current rules (HCA Supplement 25-10, August 2025):
- CHW/Rs must be certified by the NM Department of Health Office of Community Health Workers, then enroll in Medicaid (Provider Type 462, Specialty 230) and contract with the Turquoise Care MCOs.
- A CHW/R working independently completes and keeps a standing order form for each member and each date of service.
- Services are billed with CPT 98960–98962 (self-management education and training) on a CMS-1500, with an approved Z-code as the diagnosis.
- Covered services include system navigation, health promotion and coaching, and clinical support.
This was a real win for stand-alone CHW/R programs, including tribal programs that operate apart from a clinic.
The catch: Medicare comes first
Federal law makes Medicaid the payer of last resort. When a person has both Medicare and Medicaid (a “dual eligible”), Medicare must be billed first for any service it covers, and Medicaid pays only what is left.
New Mexico’s own CHW/R rules say this directly. The billing section of Supplement 25-10 and MCO Letter of Direction #38-1 states that Medicare covers Community Health Integration (CHI) services as of January 1, 2024, and that Medicare must be billed as the primary payer for CHW/R services under Medicare’s CHI guidelines. The guidance lets CHW/Rs bill Medicaid first when a client’s other primary insurance is anything except Medicare.
The same documents add a second limit: dual eligibles who have only a limited Medicaid benefit category cannot be reimbursed under Medicaid for CHW/R services at all. Full-benefit Medicaid is required.
In practice, that means two checks before every visit with an older client:
- Does the client have Medicare? If yes, the standing order alone won’t get the claim paid.
- Is their Medicaid full-benefit or limited? If limited, Medicaid won’t pay for CHW/R services regardless.
How Medicare pays for CHW work
Medicare has no benefit that pays CHWs directly, so a CHW cannot enroll in Medicare and bill on their own. Medicare pays for CHW work only through a Medicare-enrolled practitioner, mainly under the Community Health Integration codes G0019 (first 60 minutes per month) and G0022 (each additional 30 minutes).
Per the Medicare contractor guidance and the AAFP’s billing summary, the steps are:
- Initiating visit. A Medicare billing practitioner personally sees the patient (for example, an office E/M visit or Annual Wellness Visit) and identifies social needs that are getting in the way of diagnosis or treatment.
- Consent. The patient gives verbal or written consent, documented in the record.
- CHW services. The CHW provides CHI services “incident to” that practitioner’s care, under the practitioner’s general supervision.
- Billing. The same practitioner who did the initiating visit bills Medicare monthly, based on total CHW time.
A community organization can still employ the CHW and partner with a clinic or practitioner who bills. But the state’s standing order plays no part in this pathway.
| NM Medicaid standing order | Medicare CHI | |
|---|---|---|
| Who orders the service | HCA Chief Medical Officer (standing order) | The patient’s own Medicare practitioner, at an initiating visit |
| Who bills | The CHW/R or their agency | The Medicare-enrolled practitioner |
| Can the CHW enroll directly? | Yes (Provider Type 462) | No |
| Supervision | None required beyond the order | General supervision by the billing practitioner |
| Codes | CPT 98960–98962 | HCPCS G0019, G0022 |
One change worth watching: starting January 1, 2026, Medicare allows clinical psychologists, LCSWs, marriage and family therapists, and mental health counselors to bill CHI, including the initiating visit (Noridian). That opens a door for behavioral health practices to anchor CHW services for Medicare clients.
Why this hits tribal communities hardest
The people CHW/Rs serve most often — elders managing diabetes, heart disease, or kidney disease, and people with disabilities — are exactly the people most likely to have Medicare as primary coverage. In many tribal CHR programs, home visits with elders are the core of the work.
That creates a painful mismatch. The standing order was designed to free stand-alone programs from depending on a clinic. But for Medicare clients, the only billing path runs back through a clinic or practitioner, an initiating visit, and supervision. Programs in rural and frontier areas, where a primary care visit can mean a long drive and a long wait, feel this most.
Most certified CHW/Rs are never taught this. Certification training covers the work itself, not payer rules. So a new CHW/R can enroll, build a caseload, and only learn about the Medicare-first rule when claims are denied — or worse, when an audit asks for money back on claims Medicaid should never have paid first.
What CHW/Rs and programs can do now
- Check coverage before every visit. Verify eligibility in the NM Medicaid portal and note whether the client has Medicare and whether their Medicaid is full-benefit.
- Sort your caseload by payer. Know what share of your clients are Medicaid-only versus dual eligible. That number tells you how much of your work the standing order can actually cover.
- Partner with a Medicare practitioner. Clinics, tribal health programs, and primary care practices can do the initiating visit, supervise, and bill CHI for your Medicare clients. Put the arrangement, supervision, and payment split in a written agreement.
- Talk to behavioral health partners. With the 2026 Medicare change, licensed counselors and social workers can now anchor CHI services too.
- Ask the MCOs and HCA. The state requires MCOs to help CHW/Rs with enrollment and billing. Ask them how they handle claims for duals, and ask whether a Medicare denial is required before Medicaid will pay.
- Braid other funding. IHS CHR funding, grants, and MCO care coordination contracts can cover work with Medicare clients that claims won’t.
How TribeAID can help
TribeAID is a Native-led organization whose team has worked inside tribal health programs. We help CHW/R programs with certification, NPI and Medicaid enrollment, MCO credentialing, billing and coding, and program assessment — including figuring out which clients and services each payer will actually cover.
If your program is enrolled and billing but seeing denials for older clients, or you’re planning a CHW/R program and want to build the right billing model from day one, we’d like to talk.
Call us at (505) 542-1233, email info@tribeaid.org, or send us a message.
This article is general information, not legal or billing advice. Payer rules change; confirm current requirements with HCA, your MCOs, and your Medicare contractor.
Sources
- NM HCA Supplement 25-10: Implementation of CHW and CHR Updates (Aug. 28, 2025)
- NM HCA Letter of Direction #38-1: CHW and CHR Benefit (Aug. 28, 2025)
- NM HSD: New Mexico Medicaid Expands Services with Community Health Workers (June 2024)
- Noridian (Medicare contractor): Community Health Integration Services
- AAFP: Codes G0019 and G0022 for Community Health Integration Services
