summary of community health nursing

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Roles and Responsibilities of Community Health Nurses

Roles and Responsibilities of Community Health Nurses – The role of community health nurses is becoming increasingly important in today’s healthcare system. Community health nurses are healthcare professionals who work in the community to promote health and prevent disease. They are responsible for providing healthcare services to individuals, families, and communities. This article will explore the role of community health nurses in promoting health, preventing disease, and improving the quality of life in the community .

Table of Contents

Definition of Community Health Nursing

Community health nursing is a specialty in nursing that is focused on promoting and maintaining the health of individuals, families, and communities. Community health nurses work in various settings, including community health centers, schools, home care agencies, and public health departments. Their role is to provide healthcare services to individuals and families in the community, to promote health and prevent disease, and to improve the quality of life of the community.

Role of Community Health Nurse

A community health nurse, also known as a public health nurse, is a registered nurse who specializes in promoting and protecting the health of individuals and communities. Their role encompasses a wide array of responsibilities, all geared towards improving community well-being.

Assessing Community Needs

Community health nurses are at the forefront of identifying health disparities and needs within a community. They conduct comprehensive assessments to pinpoint health issues, ensuring that resources and interventions are tailored to address the specific needs of the community.

Preventive Care

One of the primary focuses of community health nurses is preventive care. They educate individuals and communities on healthy lifestyles, immunizations, and disease prevention strategies. By taking a proactive approach, they help reduce the incidence of illnesses and promote overall well-being.

Health Education and Promotion

These nurses engage in educational activities to empower individuals with the knowledge they need to make informed health decisions. They conduct workshops, seminars, and one-on-one sessions, equipping community members with the tools to maintain good health.

Community health nurses are advocates for the underserved and vulnerable populations in their communities. They work to ensure that these populations have access to healthcare services, necessary resources, and support, addressing healthcare disparities.

Emergency Response

In times of crisis, community health nurses are on the front lines. Whether it’s a natural disaster or a disease outbreak, they are well-prepared to provide immediate assistance and coordinate emergency response efforts.

Collaboration

Collaboration is key to their role. Community health nurses work closely with other healthcare professionals, community leaders, and local organizations to implement health initiatives effectively. This collaborative approach maximizes their impact on community well-being.

The Responsibilities of Community Health Nurses

Community health nurses wear many hats and are tasked with a multitude of responsibilities, all of which are vital to the well-being of the communities they serve.

Assessment and Data Collection

One of the primary responsibilities of a community health nurse is to assess the healthcare needs of a community. This involves collecting and analyzing data related to health trends, disease prevalence, and access to healthcare resources. By understanding the specific needs of the community, nurses can tailor their interventions to make the most significant impact.

Health Promotion and Education

Education is a cornerstone of the community health nurse’s role. They provide education on various health topics, ranging from nutrition and exercise to chronic disease management and preventive care. By empowering individuals with knowledge, community health nurses foster healthier behaviors and lifestyles.

Immunization and Preventive Services

Community health nurses play a crucial role in ensuring that individuals in their communities are up-to-date on vaccinations and preventive care. This is particularly important in preventing the outbreak of communicable diseases and maintaining overall community health.

Disease Management and Care Coordination

For individuals with chronic conditions or complex healthcare needs, community health nurses act as advocates and care coordinators. They help patients navigate the healthcare system, access necessary resources, and manage their conditions effectively.

In times of crises, such as natural disasters or public health emergencies, community health nurses are often on the front lines. They provide immediate care and support to affected individuals and communities, ensuring that vital healthcare services are accessible when they are needed most.

The Impact of Community Health Nursing

Strengthening communities.

The role of community health nurses extends beyond individual care; they work towards strengthening the fabric of entire communities. By promoting healthy living and preventive measures, they reduce the burden of disease and healthcare costs, leading to a healthier and more economically stable community.

Reducing Health Disparities

Community health nurses actively address health disparities by targeting underserved populations. They ensure that everyone, regardless of their socio-economic status or geographical location, has access to quality healthcare services.

Preventing Disease Outbreaks

In today’s globalized world, the risk of disease outbreaks is ever-present. Community health nurses play a pivotal role in the surveillance and early detection of potential outbreaks, thereby preventing the rapid spread of diseases.

Challenges Faced by Community Health Nurses

Community health nurses face various challenges in their work. Some of the challenges include:

• Limited Resources: Community health nurses often have limited resources to work with, which can make it challenging to provide healthcare services to the community.
• Lack of Staffing: Community health nursing positions are often understaffed, which can make it difficult to provide adequate care to the community.
• Resistance to Change: Community health nurses may face resistance to change from individuals and communities, which can make it challenging to implement new programs and interventions.
• Language and Cultural Barriers: Community health nurses may face language and cultural barriers when working with individuals and families from diverse backgrounds.
• Burnout: Community health nurses may experience burnout due to the high demands of their work and the emotional toll of working with individuals and families in the community.

Conclusion-Roles and Responsibilities of Community Health Nurses

Community health nurses play an important role in promoting health, preventing disease, and improving the quality of life in the community.

What is the primary goal of a Community Health Nurse?

Community Health Nurses aim to promote community health, prevent diseases, and improve overall well-being.

What are the major challenges faced by Community Health Nurses?

Limited resources and dealing with public health crises, such as pandemics or natural disasters, are some of the significant challenges they face.

Can Community Health Nurses specialize in certain areas of public health?

Yes, they can. They can specialize in areas such as maternal and child health, epidemiology, or environmental health.

Please note that this article is for informational purposes only and should not substitute professional medical advice.

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What to Know about the Role of a Community Health Nurse

Community health/public health nurses are the largest segment of the U.S. public health workforce, so they play a vital role in creating healthy, equitable communities. They positively influence population health and can grow rewarding careers outside traditional healthcare settings.

Keep reading to learn about the role of a community health nurse, how they make a difference, and how you can embark on a fulfilling career in community-based nursing.

What Is Community Health Nursing?

According to the American Public Health Association (APHA), community health nursing is the “practice of promoting and protecting the health of populations.” Also known as public health nursing , it strives to further social justice and equity so that every population achieves optimal health.

Community health nurses serve individuals, families, and communities. They provide preventative and primary care and participate in advocacy, policy development, and planning to address the many environmental, physical, and social determinants of health.

Community-based nursing promotes health and well-being, maintains population health, and prevents illness, injury, and disability.

What Does a Community Health Nurse Do?

The role of a community health nurse is multifaceted. Generally, community health nurses may carry out any of the 10 Essential Public Health Services , including:

• Assessing and monitoring population health.
• Strengthening, supporting, and mobilizing communities and partnerships.
• Creating, championing, and implementing policies, plans, and laws.

The day-to-day activities of a community health nurse depend on where they work. A few examples are direct patient care, community outreach, and policy and advocacy.

Direct Patient Care

The role of a community health nurse can involve providing direct patient care .

Many community health nurses serve at-risk populations, such as people experiencing homelessness, people of color, and individuals with chronic diseases. These groups have an increased risk of poor health outcomes due to the disparities they face.

Community health nurses provide culturally competent, patient-centered care. They recognize and respect the diversity of the individuals and communities they serve, tailoring their approach to meet the unique needs of each person. 

The direct patient care duties of community health nurses include:

• Performing health assessments and screenings to identify risk factors and social determinants of health.
• Educating patients on disease prevention and self-care so they can adopt healthy behaviors and manage chronic conditions.
• Triaging patients and providing medical care during natural disasters or humanitarian crises.
• Coordinating care with other healthcare providers and connecting patients to community resources and social services.

Community Outreach

Community health nurses partner with organizations and other healthcare providers to promote healthy behaviors and improved outcomes. Collaborative efforts take many forms, from health promotion and essential healthcare to community health assessment, such as:

• Developing and implementing health promotion activities, such as workshops and support groups, to empower community members to make healthy choices and improve their well-being.
• Delivering essential healthcare services to improve access and meet the community’s health needs, including blood drives and mobile clinics.
• Collaborating on health assessments, surveys, and research studies to collect data that develops programs addressing community health needs.

Policy and Advocacy

Another role of a community health nurse is promoting health equity.

Health equity refers to the presence of fair and just opportunities for everyone to attain optimal health. A society achieves health equity by changing the systems and policies that have created racial and ethnic health disparities.

Community health nurses advocate for policies that improve population health. They participate in policy analysis and development, legislative advocacy, and other activities that support the health and well-being of individuals and communities:

• Analyzing current policies about public health to identify strengths and opportunities for improvement.
• Communicating the health needs and experiences of vulnerable populations to planners and policymakers.
• Engaging with legislators to advocate for policies aligned with public health principles.
• Providing testimony and comment at legislative hearings and public meetings to influence policy making.

Where Do Community Health Nurses Work?

Community health nurses work in various settings across the public and private sectors, including:

• State and local health departments
• Schools, colleges, and universities
• Home health agencies
• Community centers
• Correctional facilities
• Advocacy groups
• Faith-based organizations

The responsibilities and role of a community health nurse vary depending on community needs and the organization's goals. However, they share a commitment to promoting health, addressing health disparities, and advancing health equity. 

Why Become a Community Health Nurse?

There are many reasons to become a nurse. Community-based nursing is an attractive career path because of the opportunities to make a wide-ranging difference, pursue diverse jobs, and enjoy job stability.

Influence Population Health

Community health nurses make a meaningful difference by improving the health of individuals, families, and their communities. They promote health, prevent disease, and improve health outcomes while reducing disparities in healthcare outcomes. Many community health nurses derive great satisfaction from creating healthier, more equitable societies.

Explore Diverse Jobs

Community health nurses have many career prospects, from government and healthcare to schools and international non-profit organizations. They work with diverse populations in the U.S. and around the world. The role of a community health nurse could focus on many different areas of public health, including direct care, public policy, or leadership.

Experience Steady Employment

The number of community health nurses has declined, creating a high demand for the profession. The percentage of RNs employed in a community or public health setting decreased from approximately 7% in 2000 to 3% in 2018. Starting a career in community-based nursing can provide job stability.

How to Become a Community Health Nurse?

There are a few steps to becoming a community health nurse. You will need to complete nursing education and then obtain nursing licensure, which involves passing a national nursing exam. Licensed RNs can apply for community-based nursing positions and pursue an optional certification in public health.

Step 1: Earn a Nursing Degree

The first step in becoming a community health nurse is earning a degree in nursing. The APHA recommends that community health nurses have a minimum of a Bachelor of Science in Nursing (BSN) because it equips nurses with foundational knowledge and skills for community nursing care:

• Clinical prevention
• Population health
• Healthcare policy
• Regulatory environments
• Interprofessional collaboration 

As a BSN student, you will grow your nursing expertise through coursework, simulations, and in-person clinical experiences .

Traditional BSN programs take four years to complete. If you have a bachelor’s degree in a non-nursing discipline, you can graduate from an accelerated BSN (ABSN) program in 11 to 18 months . ABSN programs take less time because they build on previous learning experiences, allowing students to start nursing coursework faster.

Step 2: Obtain Nursing Licensure

After graduating from a BSN program, you will need to acquire nursing licensure from the state where you plan to practice.

You will apply for licensure through your state board of nursing . The board of nursing will review your application and determine your eligibility to take the national nurse licensure exam, called the National Council Licensure Examination (NCLEX).

When you pass the NCLEX, you will become a licensed RN.

Step 3: Apply for Community Nursing Care Jobs

As a licensed RN, you can apply for community health nursing jobs. The Association of Public Health Nurses ( APHN ) and the American Public Health Association ( APHA ) are valuable resources for job opportunities. Both maintain large job listing directories.

Step 4 (Optional): Get Certified in Public Health

Community health nurses can obtain an optional certification in public health called the Certified in Public Health (CPH) credential . Administered by the National Board of Public Health Examiners, the CPH demonstrates knowledge of public health sciences and a commitment to the field.

There are several eligibility pathways for the CPH. RNs with a BSN are eligible once they have at least five years of public health work experience.

Start Your Career in Community Nursing Care with Saint Joseph’s College of Maine

Community-based nursing is a versatile and stable career path for improving social justice, health equity, and population health outcomes. Does the role of a community health nurse interest you?

You can change careers and become a BSN-prepared nurse in 15 months through the Hybrid Accelerated Bachelor of Science in Nursing (ABSN) program from Saint Joseph’s College of Maine (SJC). The accredited program is designed for individuals with a bachelor’s degree in any field, and no nursing experience is required.

Aspiring nurses choose SJC because of its emphasis on community. SJC welcomes people of all faiths, ages, and backgrounds. Together, students, faculty, and staff recognize learning as a tool for lifting themselves up in service to others.

Students learn in a community built on mutual respect and receive individualized attention, guidance, and mentoring from a team of passionate, experienced educators. Saint Joseph’s College of Maine’s BSN graduates have a first-time NCLEX pass rate of over 90%, demonstrating their readiness for a meaningful and rewarding career in nursing.

Start your path to promoting community health as a nurse. For more information, obtain your ABSN program guide today.

Community Health Nurse

• Last Updated: June 23, 2023

What Is a Community Health Nurse?

Community health nurse roles.

• CHN Certification

Community Health Nurse Salary

Community health nurses work to improve the health and well-being of the communities they serve by educating them about illness, disease prevention, safe health practices, and how to obtain health care services. They also facilitate communication between people, their families, and the medical community to improve health outcomes in vulnerable communities.

Community health nurses are instrumental in creating programs that allow communities to become healthier and often provide treatment for poor, culturally diverse, and uninsured populations. Their work may include free health care screenings, vaccinations, and other preventative care at reduced costs.

A Community Health Nurse (CHN) is a  registered nurse (RN)  who promotes health for diverse communities, infants, children, adolescents, and adults. One of the primary roles of community health nurses is to identify community health problems and provide direct care to patients and vulnerable populations who may not have access to health care or cannot afford medical services.

CHNs develop intervention plans to address individuals’ and communities’ health, safety, and quality of life needs. They may also identify health concerns that impact a specific population, conduct community assessments to identify potential problems and develop or implement various health promotion and health education programs.

What Does a Community Health Nurse Do?

In addition to the traditional role of providing direct patient care in a clinical setting, Community Health Nurses (CHNs) work to educate and empower individuals and groups to take responsibility for managing their health. They often serve in community health centers and clinics as public health education resources about specific diseases or conditions, like the importance of breast cancer screening or the dangers of smoking.

CHNs collaborate with other health professionals, educators, government agencies, and community members to plan and implement community-level public health initiatives that address social determinants of health. These nurses are an essential resource for families, educators, and patients and help better understand community health issues.

Community Health Nurse Job Description

Community health nurses play a vital role in the following:

• Educating communities about healthy lifestyles and disease prevention.
• Providing in-home treatment and support services to individuals and families who need them. This can include blood pressure monitoring, pain management, medication administration, and wound care.
• Performing free health screenings for common diseases, including obesity, diabetes, hypertension, high cholesterol, and other chronic health problems.
• Conducting health assessments to identify risk factors for chronic conditions like cardiovascular disease.
• Counseling people at increased risk of illness or injury about taking precautions to prevent illness, including performing screenings that lead to early disease detection.
• Describing how insurance works and helping uninsured or underinsured people gain access to healthcare services.
• Participating in community outreach by distributing public health information at schools, churches, workplaces, and other community settings.
• Educating the public about health and safety measures during and after natural disasters. They provide information on sanitation, clean water access, disease prevention, and psychological support to help alleviate the impact of the disaster on the community’s well-being.

The Importance of Community Health Nurses

Community health nursing is a vital part of the healthcare system. The CDC reports that 6 in 10 adults in the U.S. suffer from health problems that originate from chronic conditions and diseases acquired in the community, such as obesity, heart disease, and cancer. By working within the community, CHNs provide services for these conditions while helping to educate people on how best to prevent them.

The work of CHNs is vital in rural areas, medically underserved populations, and economically disadvantaged communities. Many people in these areas lack access to affordable healthcare options and educational support to help them maintain good health. CHNs help fill this void by providing care and nursing education to the poor, uninsured, and those with low health literacy.

There are many subfields of community health nursing, including public health nursing, school nursing, women’s health, occupational health nursing, and pediatric nursing. Nurses in these areas all play a part in preventing illness, health promotion, and addressing disparities in the community. CHNs often specialize in one or more of the following roles:

School Nurse

The unique focus of a school nurse makes them one of the most recognizable community health nurses. Their primary focus is the health and safety of a school community and managing healthcare emergencies in a school setting. The role is essential in ensuring that children are protected from preventable diseases, have access to appropriate healthcare services for injury or illness, and receive education about healthy lifestyle choices.

Behavioral Health Specialist

Mental illness is often stigmatized, but it can affect anyone at any time. Community health nurses who specialize in behavioral health work closely with individuals to assess their mental and emotional states to identify possible issues related to depression, anxiety, or other mental illnesses.

Behavioral health specialists are trained to provide mental healthcare services in schools, homes, or other community settings. They are often hired by schools that have a high population of children who face emotional, behavioral, or mental challenges. Their role involves teaching parents and teachers how best to support the child’s needs, implementing behavior management techniques at home and school, providing support during psychiatric emergencies, and helping coordinate healthcare and social services.

Occupational Health Nurse

Occupational health nurses  promote public health by reducing hazards in the workplace. They may work with employers to create healthy office spaces, train new employees to decrease injuries or risks, advise other healthcare professionals about preventative services, or analyze injury reports for patterns that could indicate a safety issue.

Women’s Health Nurse

Pediatric nurse.

A  pediatric nurse  works with children to promote healthy growth and development. They may work in the maternity ward of a hospital or an outpatient clinic or be employed by schools as part of the school health staff. Pediatric nurses care for children from birth to adolescence, including care during physical exams and treating minor injuries or illnesses. They also educate children about disease prevention, nutrition, and other lifestyle behaviors that can help them stay healthy.

Clinical Research Nurse

Clinical research nurses  are the link between healthcare providers and clinical trial researchers. They recruit study participants, work with patients through every step of the trial process, maintain patient records, and help ensure that clinical trials run smoothly to collect reliable data for use in research studies. Hospitals, clinics, or academic institutions often employ them.

Community Health Nurse Certification

Registered nurses actively involved in the community are eligible to become certified as Community Health Nurses (CHN). A certification in Community Health Nursing is available through the  American Nurses Credentialing Center  and is awarded to nurses who meet specific requirements.

Nurses who have earned this certification are prepared to work across disciplines, focusing on promoting health and wellness within communities. Nurses with this professional credential are recognized as leaders in the community health field, improving their professional status and chances for career growth and advancement.

Community health nursing is an area of specialization for registered nurses (RNs), meaning their salaries are generally similar to that of other RNs. According to employment and wage data published by the  Bureau of Labor Statistics , the mean annual wage for registered nurses across various specialties was $89,010 in May 2022.

Registered nurses in the bottom 10% of all earners reported salaries of approximately $61,250, while those in the top 10% earned more than $129,400 annually. These salary figures are based on over 500,000 RNs who responded to the BLS survey.

Community Health Nurse Resources

• National Association of Community Health Centers (NACHC)
• Association of Asian Pacific Community Health Organizations (AAPCHO)
• Robert Wood Johnson Foundation
• National Association of County and City Health Officials
• National Rural Health Association
• Association of Community Health Nursing Educators (ACHNE)
• Association of Public Health Nurses
• Council of Public Health Nursing Organizations
• American Public Health Association

Community Health Nurse FAQ

What is the difference between a community health nurse and a public health nurse.

Community health nurses and public health nurses work closely together with an aligned goal to help underserved communities. Community health nurses advocate for people within communities that need access to quality healthcare. They engage local governments and healthcare facilities to ensure these individuals receive equitable access to the necessary care. Public health nurses review scientific studies and data specific to populations and tend to work for government agencies. They focus on controlling infectious diseases through public education and programs.

What qualifications do I need to be a community health nurse?

The first step is completing a nursing program ( associate degree or bachelor’s degree ), ideally in a program with courses focused on public health policy. From there, you must pass your NCLEX-RN in the state you want to practice in. Some aspiring community nurses earn a Master’s in Public Health to serve better the communities they hope to help. The ANCC offers an  Advanced Public Health Nurse-Board Certified (APHN-BC)  credential, which requires you to be licensed to practice in the state and a graduate degree in public health sciences or community health.

What are the qualities of a community health nurse?

What makes a good community health nurse.

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• The Importance of Community Health Nurses

The Importance of Community Health Nursing

Community health nurses are a vital link in the health and welfare of neighborhoods. These registered nurses focus on improving the lives of diverse communities of infants, children, adolescents, and adults through education, prevention, and treatment.

“They assist with equalizing health care in diverse populations, so that care is more equitable, affordable, and well-coordinated,” says Sheila Rucki , faculty member in the Purdue Global School of Nursing.

“Community health nurses look at the broader needs of a population, not just an individual,” says Jessica Gordon , associate dean. “The agenda is health promotion, disease prevention, and recognizing the needs of the community.”

Learn more about the role of community health nurses, what their future looks like, and how to become one.

What Is a Community Health Nurse?

Community health nurses start by building trust and relationships with individuals and local leaders. They also develop a strong understanding of people’s backgrounds, experiences, and the social factors that influence health, with the goal of practicing cultural humility with empathetic care.

Many members of the community who take advantage of these services might not otherwise have access to private physicians or testing services, among other medical necessities.

“Ethnically diverse and culturally diverse populations are the most underserved,” Rucki says. “Those are the individual groups that benefit most from this kind of health care."

Community health nurses often participate in mobile clinics to help underserved populations, she says.

“The homeless are hard to reach because they are mobile,” Rucki says. “They benefit greatly from the care provided by community-focused providers, particularly nurses.”

What Do Community Health Nurses Do and Where Do They Work?

Community health nurses work in a variety of settings from community-based centers to government agencies to shelters to vaccine distribution sites. They build coalitions, craft policies, educate the public, manage public health programs, and more.

Services Provided by Community Health Nurses

The American Public Health Association lists 10 essential public health services provided by community nurses and other front-line professionals:

• Assess and monitor population health
• Investigate, diagnose, and address health hazards and root causes
• Communicate effectively to inform and educate
• Strengthen, support, and mobilize communities and partnerships
• Create, champion, and implement policies, plans, and laws
• Utilize legal and regulatory actions
• Enable equitable access
• Build a diverse and skilled workforce
• Improve and innovate through evaluation, research, and quality improvement
• Build and maintain a strong organizational infrastructure for public health

“Community health nurses are this incredible file cabinet of resources. They can point people in the right direction for what they need at that time,” Gordon says. “They're dealing with the community, but they provide education on where the community can get the help they need for individualized attention.”

For example, if a community has a high diabetes rate, one of the focuses for that area might be diabetes prevention education.

“Every single community health nurse works based on the population and the needs of that population specifically,” Gordon says.

Other health issues that could affect a community include:

• Substance abuse
• Teen pregnancy

Where Community Health Nurses Are Needed

Community health nurses, like other registered nurses, often work in local hospitals, trauma centers, and clinics. Many work in locations more focused on underserved communities, such as:

• Aid organizations, such as Doctors Without Borders or the Red Cross, providing disaster relief along with other daily local needs
• Community health centers, treating and educating around such topics as family planning, sexual health, and other preventative care
• Correctional facilities, working to limit the spread of communicable disease, along with running educational programs for inmates and staff
• Government agencies, helping with health policy development and implementation to create change on a large scale
• Homeless shelters, focusing on preventative care through screenings and assessments, and helping people find social service assistance
• Schools, providing education about illness prevention and good health habits, along with managing existing health problems and intervening in cases of abuse or neglect

“A lot of the community-based care centers are in parts of town or areas of the country or state where access to care might be limited or not affordable,” Rucki says. “Being based directly in the community provides access opportunities that might otherwise not be available to diverse populations.”

What Does the Future Look Like for Community Health Nurses?

Community health nurses have a bright future, but some serious challenges remain ahead.

“We’re seeing an increased need because what we thought was the traditional way of delivering care is really no longer applicable,” Rucki says. “Community-based care is becoming the primary way for many people today.”

What Job Growth Looks Like

The national nursing shortage, which has been exacerbated by the pandemic, will continue to fuel a 9% job growth rate through 2030, according to the U.S. Bureau of Labor Statistics . The agency projects employers to add 276,800 RN positions from 2020–2030.*

Because of these growing needs, becoming a community health nurse has some advantages:

• Creating strong partnerships between nurses and clients and/or community population
• Enjoying collaborative nursing care working with clients in a nonhospital setting
• Having a variety of work settings
• Helping vulnerable communities
• Providing holistic and more individualized care
• Working a convenient schedule with little to no holiday or weekend hours

According to the U.S. Centers for Disease Control and Prevention, community health worker programs particularly need nurses trained in preventing and controlling infectious diseases, to deliver home-based care to low-income people.

What Challenges Remain Ahead

The National Institutes of Health indicate that public nurses face many challenges aside from the day-to-day demands of practice, including:

• Concerns for personal safety
• Frequent overtime
• Inadequate staffing levels
• Limited management support and supervision
• On-call duties
• Professional isolation
• Restricted opportunities for career development

However, Gordon says a greater challenge facing community nurses is resistance.

“This can happen whether you're in acute care or community health, but you often see a population as a whole resisting care,” she says. “It can be incredibly frustrating when you've provided quality education and care. But you persevere. The challenge is not being rejected, it's how you overcome it.”

“It may take time to build trust in populations,” Rucki says. “Once you build trust and build that ongoing relationship, you're more likely to see change, behavior changes in people’s health care practices.”

Who Would Make a Good Community Health Nurse?

You need certain qualities and qualifications if you’re interested in becoming an effective community health nurse.

The Qualifications You Need

At a minimum, you must earn an associate or bachelor’s degree in nursing and pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN). † Some may wish to complete a two-year master's degree program in nursing. Employers often prefer community health nurses who have one to two years of nursing experience.

“Because this is such an education-heavy job, there's a strong preference toward those with a bachelor's degree,” Gordon says.

Community health nurses also are strongly encouraged to have ties to the areas in which they wish to work. Participating in volunteer programs both before and after becoming a community health nurse is highly recommended.

Community health nurses should also consider certification. One exam, the Advanced Public Health Nurse certification exam, is being phased out.

“However, there are opportunities in interprofessional groups to demonstrate excellence and receive certifications,” Rucki says.

Currently, there is no certification specific to public health nursing at the generalist level. However, nurses with a bachelor’s degree and at least five years of public health experience can obtain the Certification in Public Health (CPH). Visit the National Board of Public Health Examiners for more information on the CPH.

The Qualities You Need

A panel convened by the National Institutes of Health agreed that a successful nurse needs such qualities as being analytical, communicative, cooperative, coordinating, disseminating knowledge, empathic, evidence driven, innovative, and introspective.

Community health nurses should also be connected to their community, open-minded to those different from them, sensitive to different opinions, and objective in their view of the communities they serve.

“An essential component to these roles is a passion for serving the communities that are around them,” Gordon says. “These nurses have a connection and they understand the populations. They want to see them thrive and do better.”

“What's really so rewarding for nurses is this long-term engagement with a population,” Rucki says. “In an acute care setting, you're engaged with the patient and family for a short period of time. But in the community, they're your patients for life. You see families grow and care for them over a number of years.

“That ability to connect and learn and know about the individuals that make up your community is so rewarding for nurses.”

How Purdue Global Can Help You Become a Community Health Nurse

“Community-based nurses are very strong force for change in a community,” Rucki says. Gordon says this theme is woven throughout all programs at Purdue Global.

Purdue Global’s online nursing programs can help you start on the road to becoming a community health nurse. ‡ Reach out for more information today .

About the Author

Purdue Global

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* Job Growth Projections: National long-term projections may not reflect local and/or short-term economic or job conditions, and do not guarantee actual growth.

† NCLEX Exam : Graduates must meet state licensing and certification requirements and pass the NCLEX-RN exam to become a registered nurse or the NCLEX-PN to become a licensed practical nurse. The University cannot guarantee students will be eligible to sit for or pass exams. NCLEX is a registered trademark of the National Council of State Boards of Nursing, Inc. Licensure-track programs may limit enrollment to students in certain states. Refer to Purdue Global’s State Licensure and Certifications page for state-specific licensure.

‡ Employment and Career Advancement: Purdue Global does not guarantee employment placement or career advancement. Actual outcomes vary by geographic area, previous work experience and opportunities for employment.

Community Health Nursing (Notes)

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

4 The Role of Nurses in Improving Health Care Access and Quality

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. —Dr. Martin Luther King, civil rights activist

Nurses can be key contributors to making substantial progress toward health care equity in the United States in the decade ahead by taking on expanded roles, working in new settings in innovative ways, and partnering with communities and other sectors. But the potential for nurses to help people and communities live healthier lives can be realized only if the barriers to their working to the full extent of their education and training are removed. To this end, it will be necessary to revise scope-of-practice laws, public health and health system policies, state laws regarding the use of standing orders, and reimbursement rules for Medicare and other payers. Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. If health care equity is to be fully achieved, nursing schools will need to focus on ensuring that all nurses, regardless of their practice setting, can address the social factors that influence health and provide care that meets people where they are.

Health care equity focuses on ensuring that everyone has access to high-quality health care. As shown in the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) (see Chapter 2 ), health care is a downstream determinant of health, but disparities in health care access and quality can widen and exacerbate disparities produced by upstream and midstream determinants of health outcomes.

According to Healthy People 2020, access to quality health care encompasses the ability to gain entry into the health care system through health insurance, geographic availability, and access to a health care provider. Health care quality has been defined as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” ( IOM, 1990 , p. 4). The Agency for Healthcare Research and Quality (AHRQ) defines quality health care “as doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results” ( Sofaer and Hibbard, 2010 ). Nurses deliver high-quality care by providing care that is safe, effective, person-centered, timely, efficient, and equitable ( IOM, 2001 ).

As noted, frameworks for social determinants of health (SDOH) place the health care system downstream, often operating in response to illness, rather than upstream, impacting the underlying causes of health outcomes ( Castrucci and Auerbach, 2019 ). Therefore, health care itself does not address most of the upstream factors, or root causes of illness, that affect health equity; such upstream social factors as economic and housing instability, discrimination and other forms of racism, educational disparities, and inadequate nutrition can affect an individual’s health before the health care system is ever involved ( Castrucci and Auerbach, 2019 ). Health equity is discussed in detail in Chapter 5 . Some estimates indicate that a small portion of health outcomes is related to health care, while equity in health care is an important contributing factor to health equity ( Hood et al., 2016 ; Remington et al., 2015 ).

Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. These shifts encompass changing demographics, including declining physical and mental health; increased attention to racism and equity issues; the development and adoption of new technologies; and changing patterns of health care delivery. The widespread movement for racial justice, along with the stark racial disparities in the impacts of COVID-19, has reinforced the nursing profession’s ethical mandate to advocate for racial justice and to help combat the inequities embedded in the current health care system. The commitment to social justice is reflected in provision 9 of the Code of Ethics of the American Nurses Association ( ANA, 2015 ), and its priority has been elevated by the increased demand for social justice within communities and society at large.

Changing health outcomes will require action at all levels—upstream, midstream, and downstream—and nurses have a major role at all levels in reducing gaps in clinical outcomes and improving health care equity. Nurses can strengthen their commitment to diversity, equity, and inclusion by leading large-scale efforts to dismantle systemic contributors to inequality and create new norms and competencies within health care. In that process, nurses will need to meet the complex ethical challenges that will arise as health care reorients to respond to the rapidly changing landscape ( ANA, 2020 ; Beard and Julion, 2016 ; Koschmann et al., 2020 ; Villarruel and Broome, 2020 ). To ensure nursing’s robust engagement with these major shifts in health care and society, investments in the well-being of nurses will be essential ( ANA, 2015 ) (see Chapter 10 ).

This chapter examines ways in which nurses today work to improve health care equity, as well as their potential future roles and responsibilities in improving equity through efforts to expand access to and improve the quality of health care. Existing exemplars are also described, as well as implications of COVID-19 for health care access and quality.

NURSES’ ROLES IN EXPANDING ACCESS TO QUALITY HEALTH CARE

The United States spends more than $3.5 trillion per year on health care, 25 percent more per capita than the next highest-spending country, and under-performs on nearly every metric ( Emanuel et al., 2020 ). Life expectancy, infant mortality, and maternal mortality are all worse in the United States than in most developed countries. In the United States, moreover, disparities in health care access and health outcomes are seen across racial lines; however, being able to use social and financial capital to buy the best health care is not necessarily associated with the world’s best health outcomes. Even among White U.S. citizens and those of higher socioeconomic status (SES), U.S. health indicators still lag behind those in many other countries ( Emanuel, 2020 ). The U.S. population will not fully thrive unless all individuals can live their healthiest lives, regardless of their income, their race or ethnicity, or where they live. As discussed in Chapter 2 , however, race and ethnicity, income, gender, and geographic location all play substantial roles in a person’s ability to access high-quality, equitable, and affordable health care. A variety of professionals from within and outside of health care settings participate in efforts to ensure equitable access to care. But the role of nurses in these efforts is key, given their interactions with individuals and families in providing and coordinating person-centered care for preventive, acute, and chronic health needs within health settings, collaborating with social services to meet the social needs of individuals, and engaging in broader population and community health through roles in public health and community-based settings.

Both in the United States and globally, the rapid growth in the number of older people in the population will likely lead to increased demand for services and programs to meet their health and social care needs ( Donelan et al., 2019 ; Spetz et al., 2015 ), including care for chronic conditions, which account for approximately 75 percent of all primary care visits ( Zamosky, 2013 ). The aging population will also bring change in the kinds of care the patient population will need. Older people tend to require more expensive care, and to need increasing support in managing multiple conditions and retaining strength and resilience as they age (Pohl et al., 2018). These realities underscore the importance of designing, testing, and adopting chronic care models, in which teams are essential to managing chronic disease, and registered nurses (RNs) play a key role as chronic disease care managers ( Bodenheimer and Mason, 2016 ). Studies of exemplary primary care practices ( Bodenheimer et al., 2015 ; Smolowitz et al., 2015 ) define key domains of RN practice in primary care, including preventive care, chronic illness management, practice operations, care management, and transition care.

Since the passage of the Patient Protection and Affordable Care Act, substantial changes have occurred in the organization and delivery of primary care, emphasizing greater team involvement in care and expansion of the roles of each team member, including RNs ( Flinter et al., 2017 ). Including RNs as team members can increase access to care, improve care quality and coordination for chronic conditions, and reduce burnout among primary care practitioners by expanding primary care capacity ( Fraher et al., 2015 ; Ghorob and Bodenheimer, 2012 ; Lamb et al., 2015 ).

In primary care, RNs can assume

at least four responsibilities: 1) Engaging patients with chronic conditions in behavior change and adjusting medications according to practitioner-written protocols; 2) Leading teams to improve the care and reduce the costs of high-need, high-cost patients; 3) Coordinating the care of chronically ill patients between the primary care home and the surrounding healthcare neighborhood; and 4) Promoting population health, including working with communities to create healthier spaces for people to live, work, learn, and play. ( Bodenheimer and Mason, 2016 , pp. 11–12)

Findings from a 2013 study of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP) suggest that a large majority of LEAP primary care practices, regardless of practice type or corporate structure, use RNs as a key part of their care team model ( Ladden et al., 2013 ). This contrasts with a study of 496 practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care initiative ( Peikes et al., 2014 ) that found that only 36 percent of practices had RNs on staff, compared with 77 percent of LEAP sites ( Flinter et al., 2017 ).

The health needs of individuals exist across a spectrum, ranging from healthy people, for whom health promotion and disease prevention efforts are most appropriate, to people who have limited functional capacity as a result of disabilities, severe or multiple chronic conditions, or unmet social needs or are nearing the end of life. Access to quality health care services is an important SDOH, and equitable access to care is needed for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity” ( ODPHP, 2020 ). Likewise, “strengthening the core of primary care service delivery is key to achieving the Triple Aim of improved patient care experiences, better population health outcomes, and lower health care costs” ( Bodenheimer and Mason, 2016 , p. 23). The 2011 The Future of Nursing report echoes these themes:

while changes in the healthcare system will have profound effects on all providers, this will be undoubtedly true for nurses. Traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care. ( IOM, 2011 , p. 24)

Given the increased evidence supporting the focus on addressing social needs and SDOH to improve health outcomes, these competencies are even more important a decade later. While progress has been made, there is still work to be done, and leveraging and expanding the roles and responsibilities of nurses can help improve access to care ( Campaign for Action, n.d. ).

For people who have difficulty accessing health care because of distance, lack of providers, lack of insurance, or other reasons, nurses are a lifeline to care that meets them where they are. Nurses work in areas that are underserved by other health care providers and serve the uninsured and underinsured. They often engage with and provide care to people in their homes, they work in a variety of clinics, they use telehealth to connect with people, and they establish partnerships and create relationships in schools and communities. In addition to expanding the capacity of primary care, nurses serve in vital roles during natural disasters and public health emergencies, helping to meet the surge in the need for care (see Chapter 8 ). Yet, the potential for nurses to advance health equity through expanded access to care is limited by state and federal laws and regulations that restrict nurses’ ability to provide care to the full extent of their education and training (see Chapter 3 ). Ways in which nurses can fulfill this potential to increase access to care for populations with complex health and social needs are discussed below.

• INCREASING ACCESS FOR POPULATIONS WITH COMPLEX HEALTH AND SOCIAL NEEDS

Many individuals cannot access health care because of lack of insurance, inability to pay, and lack of clinics or providers in their geographic area. To bridge this gap, access to care is expanded through a variety of settings where nurses work, including federally qualified health centers (FQHCs), retail clinics, home health and home visiting, telehealth, school nursing, and school-based health centers, as well as nurse-managed health centers. Across all of these settings, nurses are present and facilitate access to health services for individuals and families, often serving as a bridge to social services as well.

Federally Qualified Health Centers

Through FQHCs—outpatient facilities located in a federally designated medically underserved area or serving a medically underserved population—nurses expand access to services for individuals regardless of ability to pay by helping to provide comprehensive primary health care services, referrals, and services that facilitate access to care. The role of advanced practice registered nurses (APRNs) in FQHCs has grown over time ( NACHC, 2019 ). The emerging role of RNs in FQHCs is seen in increased interactions with patients, involvement in care management, and autonomy in the delivery of care. Nurses also work to address key social factors in partnership with care coordinators, health coaches, and social workers to improve health outcomes ( Flinter et al., 2017 ).

Retail Clinics

Health care delivery in the United States has been undergoing transformation, and these changes provide new opportunities for more patients and greater access to nurses as new policies are implemented, new payment models take hold, resources are focused on SDOH, and consumerism shapes care choices. One change in particular since the prior The Future of Nursing report ( IOM, 2011 ) has been and will continue to be impactful for nursing: the emergence of nontraditional health care entities, such as retail clinics. The evolution and rapid growth of these established retail clinics provide increased accessibility of basic care, health screenings, vaccines, and other services for some populations ( Gaur et al., 2019 ). The number of such is growing rapidly, from around 1,800 in 2015 to 2,700 operating in 44 states and the District of Columbia by 2018.

Retail clinics provide more accessible primary care for some populations. In 2016, 58 percent of retail clinic visits represented new utilization instead of substitution for more costly primary care or emergency department visits ( Bachrach and Frohlich, 2016 ). Many individuals and families use retail clinics for their convenience, which includes long hours of operation, accessible location, and walk-in policies, as well as low-cost visits. These attributes are important for those with lower income or without insurance who may not have a regular source of care or be able to access a primary care provider ( Bachrach and Frohlich, 2016 ). However, research shows retail clinics are typically placed in higher-income, urban, and suburban settings with higher concentrations of White and fewer Black and Hispanic residents ( RAND Corporation, 2016 ). The RAND Corporation (2016) study found that while 21 percent of the U.S. population lived in medically underserved areas, only 12.5 percent of retail clinics were located in these areas. RAND concluded that “overall, retail clinics are not improving access to care for the medically underserved.” Thus, while these new models of care have the potential to advance health care equity and population-level health, the available data do not indicate that this potential has been realized ( RAND Corporation, 2016 ). The equity impact of these retail clincs depends in large part on who utilizes the services, and whether the utilization patterns are similar to or different from those of traditional health care.

Retail clinics are staffed largely by nurse practitioners (NPs) ( Carthon et al., 2017 ). These clinics in pharmacies and grocery stores often have been constrained by restrictive scope-of-practice laws. In 2016, a study by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research investigated scope-of-practice regulatory environments and retail-based clinic growth. Looking at three states with varying levels of scope-of-practice restrictions, the study found an association between relaxation of practice regulations and retail clinic growth. Evidence suggests that optimization of innovative health care sites such as retail clinics will require moving toward the adoption of policies that standardize the scope of practice for NPs, the providers who largely staff retail clinics ( Carthon et al., 2017 ).

Home Health and Home Visiting

Visiting people in their homes can advance equitable access to quality health care. Home health care has increased access to care for many Americans, from older individuals to medically fragile children. Yao and colleagues (2021) recently explored trends in the U.S. workforce providing home-based medical care and found that less than 1 percent of physicians participating in traditional Medicare provide more than 50 home visits each year (a rate unchanged between 2012 and 2016). By contrast, the number of NPs providing home visits nearly doubled during that same period. Home health nurses address a fragmented system by coordinating care for patients transitioning from a tertiary care facility to ongoing health care within their own homes. Since the onset of the COVID-19 pandemic, these nurses have increasingly provided families with respite for caregivers and offered mental health services in many forms, but certainly in decreasing social isolation for elderly people. Delivering care at home has offered a window for physicians and NPs to see where patients live, to engage in telehealth video calls with family members present, and to see the features of neighborhoods that impact health (e.g., sidewalks, playgrounds, stairs).

With the expansion in the home health care industry driven by an aging population, home visiting nurses are essential to providing care and enhancing health care equity ( Walker, 2019 ). Prior to 2020, Medicare rules allowed only physicians to order home health services for Medicare beneficiaries. However, the Coronavirus Aid, Relief, and Economic Security (CARES) Act permanently authorizes physician assistants and NPs to order home health care services for Medicare patients. In addition, CMS has instituted new policies outlining comprehensive temporary measures for increasing the capacity of the U.S. health care system to provide care to patients outside a traditional hospital setting amid the rising number of COVID-19-related hospitalizations nationwide. These measures include both the Hospital Without Walls and Acute Hospital Care At Home programs, both initiated during the pandemic. Under previous federal requirements, hospitals had to provide services within their own buildings, raising concerns about capacity for treating COVID-19 patients, especially those requiring ventilator and intensive care. Under CMS’s temporary new rules, hospitals can transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Provision for at-home care, which is often preferred by patients, is especially important during a crisis such as the pandemic, when hospital care means family and/or caregivers cannot be present. Moreover, some research has shown home care to be less costly and to result in fewer readmissions relative to hospital care ( Levine et al., 2020 ). These programs also will create new demand for nurses to work in the community and are the types of adaptations that occurred as a result of the COVID-19 pandemic that should remain permanent to expand high-quality access to care.

The locus of care delivery will continue to follow personal preferences of individuals and families. To improve health care access, nurses will need to be intentional about meeting patients where they are in the most literal sense, and to serve as advocates with and within public health, retail clinics, and health systems to ensure that patients can access the care they need in their homes and neighborhoods. Box 4-1 describes several innovative nurse-led, in-home care programs.

Innovative In-Home Care Programs.

In addition to home health, nurse home visiting programs often include such services as health check-ups, screenings, referrals, and guidance in navigating other programs and services in the community ( Child and Family Research Partnership, 2015 ). Growing evidence suggests that home visits by nurses during pregnancy and in the first years of a child’s life can improve the health and well-being of both child and family, including by promoting maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. This positive impact has been found to continue into adolescence and early adulthood ( NASEM, 2019 ).

The proliferation of mobile devices and applications offers an opportunity for nurses to use telehealth more broadly to connect with individuals. Telehealth, including video visits, email, and distance education, serves as a tool to connect with people on an ongoing basis without their having to leave their homes, workplaces, or other settings, and allows for long-distance patient and clinician contact for purposes of clinical interventions, health promotion, education, assessment, and monitoring. The use of telehealth is especially helpful for those who have difficulty traveling to obtain care and those who reside in rural or remote areas. Vulnerable populations with multiple chronic illnesses, poor health literacy, and lack of supportive resources may benefit the most from telehealth use. However, use of telehealth or virtual health tools is limited by access to reliable Internet connections and the availability of the necessary hardware, including smartphones, computers, or webcams. A recent report in the Journal of the American Medical Association looks at 41 FQHCs serving 1.7 million patients. Prior to the COVID-19 pandemic, there was minimal telehealth use at these facilities. During March 2020, FQHCs rapidly substituted in-person visits with telephone and video visits. For primary care, however, 48.5 percent of telehealth visits occured by telephone and 3.4 percent by video. In addition, CMS estimated that 30 percent of telehealth visits were audio-only during the pandemic. These numbers indicate that telehealth appointments for lower-income Americans were in large part audio-only, raising questions about the quality of care ( Uscher-Pines et al., 2021 ).

There have been examples of telehealth activities that have demonstrated great success. The Mississippi Diabetes Telehealth Network, for example, implemented a program that uses telehealth in the home as a viable way to bring a care team to patients to assist them as they manage their illnesses. NPs provide daily health sessions and remote monitoring for individuals with diabetes ( Davis et al., 2020 ; Henderson et al., 2014 ). A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period, finding a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values ( Davis et al., 2020 ). In another example, Mercy Hospital, a virtual care center, delivers telehealth services to rural communities in Arkansas, Kansas, Missouri, and Oklahoma. One of its many services is Nurse on Call, which provides timely clinical advice and is available around the clock. In still another example, Banner Health’s skilled nursing model delivers home care combined with telehealth services to people at home instead of their having to move to a nursing home facility ( Roth, 2018 ).

School Nursing

School nurses are front-line health care providers, serving as a bridge between the health care and education systems. Hired by school districts, health departments, or hospitals, school nurses attend to the physical and mental health of students in school. As public health sentinels, they engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children. School nurses are essential to expanding access to quality health care for students, especially in light of the increasing number of students with complex health and social needs. Access to school nurses helps increase health care equity for students. For many children living in or near poverty, the school nurse may be the only health care professional they regularly access.

School nurses treat and help students manage chronic health conditions and disabilities; address injuries and urgent care needs; provide preventive and screening services, health education, immunizations, and psychosocial support; conduct behavioral assessments; and collaborate with health care providers, school staff, and the community to facilitate the holistic care each child needs ( Council on School Health, 2008 ; Holmes et al., 2016 ; HRSA, 2017 ; Lineberry and Ickes, 2015 ; Maughan, 2018 ). By helping students get and stay healthy, school health programs can contribute to closing the achievement gap ( Basch, 2011 ; Maughan, 2018 ). According to Johnson (2017) ,

Healthy children learn better; educated children grow to raise healthier families advancing a stronger, more productive nation for generations to come. School nurses work to assure that children have access to educational opportunities regardless of their state of health. (p. 1)

Meeting the mental health needs of children can be particularly challenging. Researchers estimate that about a quarter of all school-age children and adolescents struggle with mental health issues, such as anxiety and depression. Approximately 30 percent of student health visits to the school nurse are for mental health concerns, often disguised by complaints of headaches and stomachaches ( Foster et al., 2005 ). School nurses have experience with screening students at risk for a variety of such concerns and can assist students in addressing them ( NASN, 2020a ). However, most youth—nearly 80 percent—who need mental health services will not receive them ( Kataoka et al., 2005 ); schools are not always equipped to deal with students’ emotional needs, and parents often lack the awareness or resources to get help for their children. Additionally, a recent study found disparities in access to mental health treatment for students along racial and ethnic lines ( Lipson et al., 2018 ), and structural racism undergirds many risk factors for mental illness (see Chapter 2 ). The COVID-19 pandemic has revealed—and exacerbated—inequities among children of different incomes and races/ethnicities. School closures and social isolation have affected all students, but especially those living in poverty. In addition to the damage to student learning, the loss of access to mental health services that were offered by schools has resulted in the emergence of a mental health crisis ( Leeb et al., 2020 ; Patrick et al., 2020 ; Singh et al., 2020 ).

Schools are increasingly being recognized not just as core educational institutions but also as community-based assets that can be a central component of building healthy and vibrant communities ( NASEM, 2017 ). Accordingly, schools and, by extension, school nurses are being incorporated into strategies for improving health care access, serving as hubs of health promotion and providers of population-based care ( Maughan, 2018 ). Yet, while there have been calls for every school to have access to a nurse ( Council on School Health, 2016 ; NASN, 2020b ), only 39.9 percent of schools employed a full-time nurse in 2017. The remainder of schools (39.3 percent) employed a part-time nurse or did not employ a nurse at all (25.2 percent) ( Willgerodt, 2018 ). The availability and staffing levels of school nurses vary greatly by geography ( Willgerodt, 2018 ) (see Figure 4-1 ).

Licensure staffing patterns (paid and unpaid volunteer) by geography. SOURCE: Data from Willgerodt, 2018.

To address the lack of health care resources in rural school settings, telehealth programs have been implemented with success ( RHI, 2019 ). An example is Health-e-Schools, in which onsite school nurses connect sick students with health care providers. The program employs a full-time, off-site family NP who uses telehealth to evaluate and diagnose patients with such health issues as earaches, sore throats, colds, and rashes, as well as to provide sports physicals, medication, chronic disease management, and behavioral health care. It began as a telehealth program implemented by only 3 schools in 2011 and has since expanded to more than 80 schools serving more than 25,000 students. Health-e-Schools has helped increase classroom attendance and decrease the amount of time parents or guardians must take off from work to bring their children to appointments. This model relies heavily on the school nurses employed within each school district to serve as primary telehealth providers, thus requiring that funding be allocated to provide a school nurse in each school.

School-Based Health Centers

School-based health centers (SBHCs) also make care accessible to students in the school setting. In 2017, 2,584 SBHCs were operating in the United States ( Love et al., 2019 ). SBHCs often operate as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department; more than half are supported by or are an extension of FQHCs ( SBHA, n.d. ). SBHC services include primary care, mental health care, social services, dentistry, and health education, but vary based on community needs and resources as determined through collaborations among the community, the school district, and health care providers ( CPSTF, 2015 ; HRSA, 2017 ). Services are provided by interprofessional teams of health care professionals that include nurses, mental health care providers, physicians, nutritionists, and others. As of 2017, NPs provided primary care services onsite and through telehealth services at 85 percent of SBHCs ( Love et al., 2019 ; SBHA, 2018 ).

One example of an SBHC is the nurse-run Vine School Health Center (VSHC) located at the Vine Middle Magnet School in Knoxville, Tennessee, a Title I school where 100 percent of the students qualify for free lunch. VSHC provides onsite and telehealth services to anyone up to 21 years of age who lives in the county. It also serves 10 other Title I schools through direct health care or telehealth services. The clinic is a partnership between the University of Tennessee College of Nursing and Knox County Schools and is staffed by nurses, nursing students, social workers, and special education professionals. Staff assist families with social needs, including food, housing, clothing, linkages to health insurance, and financial support for rent and utilities ( AAN, 2015 ; Pittman, 2019 ). Services rendered during the 2016–2017 school year included 1,110 early and periodic screening, diagnostic and treatment (EPSDT) exams; 1,896 immunizations; 4,455 physical health visits; and 1,796 mental health clinic visits. VSHC estimates that its services enabled the avoidance of more than 2,500 potential emergency room visits per academic year, associated with savings of about $375,000 per year ( AAN, 2015 ).

• IMPROVING THE QUALITY OF HEALTH CARE

Access to comprehensive health care services is a precursor to equitable, quality health care. Nurses are uniquely qualified to help improve the quality of health care by helping people navigate the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is culturally respectful and appropriate. Nurses can help overcome barriers to quality care, including structural inequities and implicit bias, through care management, person-centered care, and cultural humility.

Care Management

In the current health care system, care is often disjointed, with processes varying between primary and specialty care and between traditional and emerging care sites. People may not understand the processes of the health care system, such as where they will receive care, how to make appointments, or the various providers with whom they may come into contact. Perhaps most important, patients may not understand why all the providers across settings where they receive care should be knowledgeable about the services they receive and the problems that have been identified to ensure seamless, continuous high-quality care. Social factors affecting people with complex health needs may also adversely affect their ability to receive optimal care. Care management, care coordination, and transitional care are activities that nurses perform as members of a health care team to decrease fragmentation, bolster communication, and improve care quality and safety. A care management approach is particularly important for people with complex health and social needs, who may require care from multiple providers, medical follow-up, medication management, and help in addressing their social needs.

Care management—a set of activities designed to “enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self-care”—helps ensure seamless care ( CHCS, 2007 ; Goodell et al., 2009 ). The components of care management include care coordination, transitional care, and social care.

Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” It is needed both to overcome obstacles of the health care system, such as fragmentation, communication, and billing/cost, and to increase access ( McDonald et al., 2007 , p. 4).

Transitional care entails coordinating care for people moving between various locations or levels of care, providing navigation, coordination, medication reconciliation, and education services ( Storfjell et al., 2017 ). The Transitional Care Model, developed by Mary Naylor (see Box 4-2 ), and the Care Transitions Intervention, developed by Eric Coleman, are prominent nurse-centered care models focused on the often disjointed transition from an inpatient hospital stay to follow-up ambulatory care. Both models engage people with chronic illness from hospitalization to postdischarge, and employ a nursing coach or team “to manage clinical, psychosocial, rehabilitative, nutritional and pharmacy needs; teach or coach people about medications, self-care and symptom recognition and management; and encourage physician appointments” ( Storfjell et al., 2017 , p. 27). Both reduce readmissions and costs ( Storfjell et al., 2017 ).

Transitional Care Model.

Health care delivery models that incorporate social care have created critical roles for nurses in coordinating care across providers and settings and collaborating with other professionals and community resources to improve the health of individuals with complex health and social needs. Chapter 5 provides examples of nurse-centered programs incorporating social care. Nurses are vital to carrying out these functions of care management. Common to nurses’ roles are functions including providing care coordination, developing care plans based on a person’s needs and preferences, educating people and families within care settings and during discharge, and facilitating continuity of care for people across settings and providers ( ANA, n.d. ).

Person-Centered Care

The person-centered care model embraces personal choice and autonomy and customizes care to an individual’s abilities, needs, and preferences ( Kogan et al., 2016 ; Van Haitsma et al., 2014 ). Through person-centered care, nurses collaborate with people, including the patient and other care team members, to deliver personalized quality care that addresses physical, mental, and social needs ( CMS, 2012 ; Terada et al., 2013 ). Features of person-centered care include an emphasis on codesign of interventions, services, and policies that focus on what the person and community want and need; respect for the beliefs and values of people; promotion of antidiscriminatory care; and attention to such issues as race, ethnicity, gender, sexual identity, religion, age, socioeconomic status, and differing ability status ( Santana et al., 2018 ). And person-centered care focuses not only on the individual but also on families and caregivers, as well as prevention and health promotion. Integrating person-centered care that improves patient health literacy is necessary to ensure patient empowerment and engagement and maximize health outcomes. Health literacy ensures that “patients know what they must do after all health care encounters to self-manage their health” ( Loan et al., 2018 , p. 98).

Research has demonstrated the efficacy of person-centered care, for example, in reducing agitation, neuropsychiatric symptoms, and depression, as well as improving quality of life, for individuals with dementia ( Kim and Park, 2017 ). In another example, people with acute coronary syndrome receiving person-centered care reported significantly higher self-efficacy ( Pirhonen et al., 2017 ). Person-centered care is person-directed, such that people are provided with sufficient information to help them in making decisions about their care and increase their level of engagement in care ( Pelzang, 2010 ; Scherger, 2009 ), and nurses who engage people in their care are less likely to make mistakes ( Leiter and Laschinger, 2006 ; Prins et al., 2010 ; Shiparski, 2005 ). Person-centered care leads to better communication between patients and caregivers and improves quality of care, thereby increasing patient satisfaction, care adherence, and care outcomes ( Hochman, 2017 ).

Cultural Humility

As discussed in Chapter 2 , implicit bias can lead to discrimination against others. In particular, structural racism in health care compromises the ability to deliver culturally competent care ( Evans et al., 2020 ).

Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession. ( Villaruel and Broome, 2020 , p. 375)

Nurses may contribute to structural inequities in how they facilitate or hamper access to quality health care services since they are frequently the first point of contact for many individuals who need care. Cultural humility—“defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions” ( Agner, 2020 , p. 1)—is therefore essential for nurses.

Cultural humility enables nurses to participate in more respectful partnerships with patients in order to advance health care equity. According to Foronda and colleagues (2016) , cultural humility has been found to result in effective treatment, decision making, communication, and understanding; better quality of life; and improved care. In contrast, clinicians with implicit bias may show less compassion toward and spend less time and effort with certain patients, leading to adverse assessment and care ( Narayan, 2019 ). Because implicit bias can negatively affect patient interactions and health outcomes, it is important for nurses to be aware of their bias and how it may directly or indirectly impact patient interactions and the quality of care they provide ( Hall et al., 2015 ).

Multiple strategies exist to help nurses achieve cultural humility and manage implicit bias to ensure that they provide high-quality, equitable care. Chapter 7 details the importance of incorporating cultural humility in nursing education. Instead of focusing broadly on the general population, quality improvement interventions characterized by cultural humility focus on needs that are unique to people of color (POC) and tailor care to overcome cultural and linguistic barriers that cause disparities in care (Green et al., 2010). With this approach, data on disparities are used to assess an intervention, with an emphasis on addressing barriers that are specific to underrepresented groups ( ANA, 2018 ; Green et al., 2010; Villarruel and Broome, 2020 ). Box 4-3 describes culturally and linguistically appropriate services, designed to equip nurses with the knowledge, skills, and awareness to provide high-quality care for all patients regardless of cultural or linguistic background.

Culturally and Linguistically Appropriate Services.

When nurses are educated and empowered to act at multiple levels—upstream, midstream, and downstream—they help reduce the effects of structural inequities generated by the health care system. This includes education about how structural inequities may affect their practice environments (as well as research and policy) and, by association, the people with whom they work in clinical and community-based settings (see the detailed discussion of nursing education in Chapter 7 ).

• IMPLICATIONS OF COVID-19 FOR HEALTH CARE EQUITY

The COVID-19 pandemic has highlighted the pivotal role of nurses in addressing health care equity. During public health emergencies, nurses in hospitals and in public health and other community settings need to function collaboratively and seamlessly. The pandemic has heightened the need for team-based care, infection control, person-centered care, and other skills that capitalize on the strengths of nurses ( LaFave, 2020 ). Broadening of scope-of-practice regulations and expansion of telehealth services during the COVID-19 pandemic have allowed nurses to practice to the full extent of their education and training, providing equitable care and increasing access to care.

The surge of critically ill people due to the pandemic created the need to rapidly increase the capacity of the health care workforce, especially to replenish workforce members who needed to quarantine or take time to care for sick family members or friends ( Fraher et al., 2020 ). In response, multiple governors issued executive orders expanding the scope of practice for NPs. As of April 10, 2020, five states (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) had temporarily suspended all practice agreement requirements, providing NPs with full practice authority ( AANP, 2020 ). Thirteen states (Alabama, Arkansas, Indiana, Massachusetts, Michigan, Mississippi, Missouri, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) had enacted a temporary waiver of selected practice agreement requirements. By December 7, 2020, executive orders had expired for Kansas, Michigan, and Tennessee, and all practice agreement requirements had been temporarily suspended for Kentucky, Louisiana, New Jersey, New York, Virginia, and Wisconsin ( AANP, 2020 ). Maintaining these broadened scopes of practice for nurses after the pandemic has ended would increase NPs’ opportunities to increase access to quality health care for individuals with complex health and social needs.

Hospitals are also redeploying health care workers—physicians, NPs, nurses, and others—from areas with decreasing patient volumes (resulting from, for example, limitations on elective procedures) to higher-need intensive care unit (ICU), acute care, and emergency service areas. For example, nurse anesthetists have been redeployed from operating rooms to ICUs to intubate and place central lines for patients in the surge response to COVID-19 ( Brickman et al., 2020 ). As of December 2020, CMS was finalizing changes that allow NPs to “supervise the performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians” ( CMS, 2020a ). These changes will help make permanent some of the workforce flexibilities that were allowed during the pandemic.

Although much attention has been paid to the dire need for health care supplies and hospital beds to treat patients with severe cases of COVID-19, less attention has been directed at impacts of the pandemic on communities; their ability to weather the crisis; and individuals’ physical, mental, and social health. Nurses, including public health nurses, working in and with communities continue to be critical to efforts to contain the COVID-19 pandemic, as well as other pandemics that may occur in the future.

Older Adults

Older adults have been disproportionately affected by COVID-19, and older POC are even more likely to experience disproportionate morbidity and mortality. CMS data show that Black Medicare beneficiaries were hospitalized four times as often and contracted the virus nearly three times as often compared with Whites of similar age ( CMS, 2020b ; Godoy, 2020 ). According to the Centers for Disease Control and Prevention (CDC), 8 of 10 deaths from COVID-19 in the United States have been among adults 65 and older ( Freed et al., 2020 ). Nursing homes have been particularly hard hit and faced multiple unique challenges in serving those most vulnerable to the virus.

The pandemic has had significant emotional, social, and mental health effects on older adults and their caregivers, and nurses and nursing assistants in nursing homes have borne a great burden in carrying out the front-line work of trying to keep residents healthy, care for recovered patients, and help mitigate isolation and its detrimental effects on residents. These tasks in many cases have been performed in the absence of residents’ family members and friends, who have not been allowed to visit as part of efforts to prevent the spread of infection. Inside nursing homes, the nursing staff have had to act as both caregivers and confidants, carrying out their usual tasks while also supporting many residents through confusion, depression, and suicidal ideation. In multigenerational homes, additional steps have been required to mitigate COVID-19 risk for older adults, such as using separate bathrooms, wearing masks within the household if someone is sick, or avoiding visitors. Demand for home health nursing services, inclusive of following strict public health measures (masks, handwashing, quarantining), has increased during the pandemic.

Changes in Medicare policy during the COVID-19 pandemic have given older adults greater access to a variety of mental health services, including those provided in their homes. Access to telehealth has also been expanded to meet the urgent need to provide safe access to care. Medicare payment for telehealth visits in nursing homes was previously restricted to rural areas, but under the 1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS temporarily broadened access to telehealth services to ensure that Medicare beneficiaries could access services from the safety of their homes ( CMS, 2020b ). Accordingly, NPs and other health care professionals have used telehealth to screen people for COVID-19 and treat noncritical illnesses that can be managed at home.

Telehealth also has helped address concerns about workforce capacity for adult health care due to the surging numbers of COVID-19 cases and reports of exposure among health care workers: “as many as 100 health care workers at a single institution have to be quarantined at home because of COVID-19” ( Hollander and Carr, 2020 ). NPs who are quarantined because of exposure can provide telehealth services. It is important to note that the barriers discussed earlier due to restrictive scope-of-practice regulations may include limitations on providing telehealth services across state lines. Recognition of clinical licenses across states, such as through interstate agreements, could ease these barriers ( NQF, 2020 ).

Although CDC has reported that COVID-19 poses a relatively low risk for children, research on natural disasters has shown that, compared with adults, children are more vulnerable to the emotional impact of traumatic events that disrupt their daily lives. The pandemic has required that children make significant adjustments to their routines (e.g., because of school and child care closures and the need for social distancing and home confinement), disruptions that may interfere with a child’s sense of structure, predictability, and security. Young people—even infants and toddlers—are keen observers of people and environments, and they notice and react to stress in their parents and other caregivers, peers, and community members ( Bartlett et al., 2020 ). While most children eventually return to their typical functioning when they receive consistent support from sensitive and responsive caregivers, others are at risk of developing significant mental health problems, including trauma-related stress, anxiety, and depression. Children with prior trauma or preexisting mental, physical, or developmental problems, as well as those whose parents struggle with mental health disorders, substance misuse, or economic instability, are at especially high risk for emotional disturbance. Thus, in addition to keeping children physically safe during a public health emergency such as the COVID-19 pandemic, it is important to care for their emotional health ( Bartlett et al., 2020 ).

Barriers to mental health care result in serious immediate and long-term disadvantages for young people, especially students of color. Mental health—a key component of children’s healthy development—was already a growing concern prior to the pandemic and the concurrent nationwide protests in response to racial injustice and anti-Black racism, with the demand for mental health services among U.S. adolescents increasing in the past decade ( Mojtabai et al., 2020 ). This concern has been fueled by increases in the incidence of anxiety and depression, as well as a trend in which victims of suicide have been younger. As noted earlier, programs such as Nurse-Family Partnership (see Box 4-1 ), as well as school nurses and school-based health centers, represent channels through which nurses can assist children and families with health care access to address mental health needs.

The health care system is being transformed by an increased focus on community-based coordinated care and the use of technology to improve communication so as to achieve better population health outcomes at lower cost. At the local level, providers in public health and school settings can collaborate strategically to increase their community’s capacity to address the root causes of illness and improve overall population health by implementing broad social, cultural, and economic reforms that address SDOH. Such collaboration can benefit the entire health care system by leading to seamless care, reducing duplicative services, and lowering the costs of care.

• CONCLUSIONS

Whether in an elementary school, a hospital, or a community health clinic, nurses work to address the root causes of poor health. As the largest and consistently most trusted members of the health care workforce, nurses practice in a wide range of settings. They have the ability to manage as well as collaborate within teams and connect clinical care, public health, and social services while building trust with communities. However, nurses are limited in realizing this potential by state and federal laws that prohibit them from working to the full extent of their education and training. The COVID-19 pandemic in particular has revealed that the United States needs to do a much better job of linking health and health care to social and economic needs, and nurses are well positioned to build that bridge.

Conclusion 4-1: Nurses have substantial and often untapped expertise to help individuals and communities access high-quality health care, particularly in providing care for people in underserved rural and urban areas. Improved telehealth technology and payment systems have the potential to increase access, allowing patients to obtain their care in their homes and neighborhoods. However, the ability of nurses to practice fully in these and other settings is limited by state and federal laws that prohibit them from working to the full extent of their education and training. Conclusion 4-2: Nurses are uniquely qualified to improve the quality of health care by helping people navigate the health care system; providing close monitoring, coordination, and follow-up across the care continuum; focusing care on the whole person; and providing care that is culturally respectful and appropriate. Through a team-based approach, nurses can partner with professionals and community members to lead and manage teams and connect clinical care, public health, and social services while building trust with communities and individuals.

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17.4 Formulating a Nursing Community Diagnosis and Plan of Care

Learning outcomes.

By the end of this section, you should be able to:

• 17.4.1 Utilize various approaches and assessment findings to identify and prioritize individual, family, community, system, and population health concerns.
• 17.4.2 Appraise the level of nursing intervention to make the most impact.
• 17.4.3 Integrate individual, family, community, system, and population experiences and perspectives in designing plans of care.
• 17.4.4 Develop a nursing community diagnosis and plan of care tailored to community culture.

Formulating a nursing community diagnosis and plan of care is similar to individual nursing community diagnosis and care planning. First, the CHA team identifies and prioritizes community health concerns. Next, the team develops community nursing diagnoses. Finally, the team tailors a community health improvement plan to community culture.

Prioritize Health Concerns

The CHA team uses the identified problem list created during analysis to prioritize community problems based on:

• Extent of the problem (percent of the population affected by the problem and perception of health needs)
• Relevance of the problem (degree of risk and economic loss)
• Estimated effect of the intervention (impact, improvement of health outcomes, and potential adverse effects)

Health priorities should be those for which intervention would make the most impact on the community as a whole or for a specific at-risk population. Health priorities are those that have the

• highest community perception of need,
• largest reach,
• highest degree of risk if unaddressed,
• greatest economic impact,
• greatest opportunity for improvement in health outcomes,
• opportunity to promote health equity and reduce health disparities, and
• least adverse effect on the population.

The team should base priorities on community strengths and available resources to increase the possibility of successful implementation of programs targeting those priorities. Resources include current and potential partnerships and collaborations, human resources or capacity, and funding. Health concerns may also be prioritized because they align with state and federal priorities, allowing for benchmarking and comparison to state and local data. Additionally, monies are usually available to fund programs that align with state or federal priorities.

The method the CHA uses to prioritize health concerns is determined by the CHA model, framework, or tool it chose at the beginning of the process. For example, a CHA team using the MAPP framework will first rank identified problems individually and then use a consensus to choose priorities or strategic issues. MAPP offers several tools to guide this process (NACCHO, 2023). In contrast, a CHA team using the Community Health Assessment toolkit would first identify specific criteria for prioritization and then choose an approach, such as group vote with majority deciding, averaging individual rankings, or using a matrix to weigh and rank criteria according to several factors (baseline data, feasibility, availability of resources, etc.) (AHA, 2017).

PHAB (2022) requires at least two health priorities, but most community care plans or community health improvement plans include at least three priority topics. Choosing health priorities also includes picking at least one health outcome indicator to measure health problem changes and identify the priority population of focus. For example, a team may choose mental health and addiction as a health priority. The priority outcome of this focus should then align with data collected during the CHA. Examples of mental health and addiction topic priority outcomes are “decrease the percentage of the community with depression,” “decrease suicide deaths,” and “decrease drug overdose deaths.”

Develop the Community Nursing Diagnosis

The community nursing diagnosis includes only one identified priority and the aggregate (population) affected, and it provides a rationale. A community nursing diagnosis should be written for each selected priority and include these three parts:

• Risk of: Identifies a specific problem or health risk faced by the community
• Among: Identifies the specific community aggregate with whom the nurse will be working in relation to the identified problem or risk
• Related to: Describes characteristics of the community

The community problem must be observable and measurable at the aggregate level. It considers which aggregate the risk affects most and which intervention will have the biggest impact. The community’s characteristics may contribute to the identified problem and/or be strengths of the community that can be built upon.

Examples of appropriately written community nursing diagnoses are as follows:

• Risk of drug overdose among Hardin County adults related to increased opioid usage, presence of fentanyl, lack of available naloxone, ineffective drug misuse prevention programs, and decreased access to drug rehabilitation programs
• Risk of infant and child malnutrition among families in Richmond County related to lack of regular developmental screenings, knowledge deficit about infant-related and child-related nutrition, knowledge deficit about available community resources, and lack of access to healthy foods
• Risk for cardiovascular disease among Bailey County adults related to sedentary lifestyles, lack of walking trails, lack of safe sidewalks, and lack of affordable exercise facilities

Unfolding Case Study

Part b: conducting a cha.

Read the scenario, and then answer the questions that follow based on all the case information provided in the chapter thus far. This case study is a follow-up to Case Study Part A.

After selecting the PRECEDE-PROCEED model, Tia’s CHA team completed phases 1–3. During the assessment, the team collected the following data:

• GIS data shows one neighborhood with a disproportionate number of drug overdoses. This area also has high poverty and unemployment rates and is located by an entrance/exit on the interstate.
• EMS calls for overdoses have tripled since the last CHA.
• Drug overdose deaths are higher than the national benchmark (Healthy People 2030).
• Provider opioid prescriptions have decreased in the area.
• Reported opioid use (attained by any method—legal or illegal) has increased. Heroin usage has increased by 10 percent.
• Availability of heroin mixed with fentanyl has increased over the past 6 months.
• Infection rates related to needle use have increased at the local hospital.
• Local schools continue to educate on drug abstinence using the Drug Abuse Resistance Education (DARE) program.
• Naloxone training is available from the public health department, but utilization goals have not been reached.
• Local EMS staff are volunteers, and the station is not regularly staffed.
• A drug rehabilitation center is located within the community but frequently has a waiting list for outpatient appointments and inpatient admission.

Although the PRECEDE-PROCEED model does not require a community nursing diagnosis, the team decided to create one in order to clearly identify the aggregate and characteristics of the community.

The team has started planning for program implementation and wants to begin by promoting and enhancing available community resources, such as education within the schools, community naloxone training, education for providers related to opioid prescriptions, and drug rehabilitation. According to the PRECEDE-PROCEED model, phase 4, administrative and policy diagnosis, the team focuses on administrative and organizational concerns that should be addressed prior to program implementation.

• Risk for overdose among opioid/heroin users related to increased availability of heroin mixed with fentanyl, inconsistent EMS staffing, lack of availability/access to drug rehabilitation resources, increased opioid usage in the community, lack of knowledge of consequences of opioid misuse, and lack of utilization of community naloxone training
• Opioid misuse among community members living next to the highway who are unemployed and lack financial resources
• Risk for infection related to heroin injection, lack of knowledge of aseptic technique for injection, and availability of clean needles
• Increased opioid use in the county related to availability of heroin
• Reduced rates of opioid prescriptions by providers in the area
• Availability of appointments at the local drug rehabilitation center
• Response times of local EMS to overdose calls
• Increased availability of heroin in the community

Develop the Community Health Improvement Plan

The CHA team uses the identified priorities and community nursing diagnoses to develop the community health improvement plan (CHIP), the care plan for the entire community. PHAB (2022) defines the CHIP as a long-term systematic plan to address issues identified in the CHA that describes how the health department and community will work together to improve population health. Frequently, the public health department holds a leadership role, collaborating with various diverse community organizations to create the CHIP. The members of the CHA team are also usually involved in the CHIP process. As stated previously, the team members are individuals who either work or live within the community, ensuring the CHIP represents the community culture and values. The plan outlines goals and strategies community organizations, coalitions, and members will use to address priority health problems.

The team considers potential intervention s for each identified priority. First, the team discusses existing community programs that may meet the community health need. The team performs a gap analysis to determine where the community should expand its efforts to meet community health needs. A gap analysis identifies and addresses the disparity between what is desired and real-world conditions (Davis-Ajami et al., 2014). For example, access to primary health care is a desired community health outcome for all. In reality, all people do not have access to a primary health care provider. A gap analysis identifies the disparity and potential solutions to reduce it. The team brainstorms strategies to enhance current programming and identify potential new interventions to fill the gaps noted to promote health and prevent disease. The team searches for new interventions that meet community needs and are innovative, evidence-based, most impactful, and sustainable. The team should also consider new partnerships to assist with planning or implementation. Finally, the team may complete a SWOT analysis to identify strengths, weaknesses, opportunities, and threats that may influence health outcomes or may promote or hinder possible interventions. The Minnesota Department of Health provides more information on completing a SWOT analysis . Overall, the team should select the best intervention after considering the various factors discussed.

The CHIP is designed to immediately follow the CHA and is updated with the CHA. So if the CHA process occurs every 3 years, the CHIP should be written as a three-year plan. CHIP interventions must align with chosen priorities and include measures for evaluation related to the rationale identified within the corresponding community nursing diagnosis. Current community resources and strengths are considered and integrated into interventions. The CHIP development also considers currently available and potential resources (such as grants) and partnerships. Community interventions are chosen when they are impactful, have the largest reach, are feasible, are innovative, are evidence-based, and can be completed within the CHIP time frame.

CHIP development continues by detailing goals and objectives, action steps, timetables, priority target populations, indicators to measure strategy impact, and accountability. Objectives should be SMART (specific, measurable, achievable, relevant, and time-bound). Action steps are specific and are listed by year of implementation. The time to complete each action step, target population, health indicator to measure the strategy, and responsible individual or organization is determined. Other details of the interventions are further detailed by the responsible individual or organization during program planning. See Planning Health Promotion and Disease Prevention Interventions for more information on writing SMART objectives .

The CHA and CHIP provide community organizations and health care systems with a common plan for addressing community health issues. The community is a partner in planning for health promotion and disease prevention efforts with community perspectives and community engagement at the center of the process. A comprehensive CHA provides evidence for community health priorities and social determinants of health impacting community health outcomes. The CHIP utilizes established community resources to combat identified priorities and reduce health disparities caused by determinants of health.

This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.

Want to cite, share, or modify this book? This book uses the Creative Commons Attribution License and you must attribute OpenStax.

Access for free at https://openstax.org/books/population-health/pages/1-introduction

• Authors: Jessica Ochs, Sherry L. Roper, Susan M. Schwartz
• Publisher/website: OpenStax
• Book title: Population Health for Nurses
• Publication date: May 15, 2024
• Location: Houston, Texas
• Book URL: https://openstax.org/books/population-health/pages/1-introduction
• Section URL: https://openstax.org/books/population-health/pages/17-4-formulating-a-nursing-community-diagnosis-and-plan-of-care

© May 15, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.

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CY 2025 Physician Fee Schedule Proposed Rule Summary – Part I

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On July 10, 2024, CMS placed on public display a proposed rule relating to the Medicare physician fee schedule (PFS) for CY 2025 and other revisions to Medicare Part B policies. The proposed rule was published in the July 31, 2024, issue of the Federal Register. If finalized, policies in the proposed rule generally would take effect on January 1, 2025. The 60-day comment period ends at close of business on September 9, 2024. HFMA is providing a summary in three parts. Part I covers sections I through III.O (except for Section G: Medicare Shared Savings Program Requirements) and the Regulatory Impact Analysis. Part II will cover the Medicare Shared Savings Program Requirements. Part III will cover the updates to the Quality Payment Program. Part I includes payment policies under the PFS, including caregiver training services, the evaluation and management (E/M) office/outpatient (O/O) complexity add-on code, telehealth services, advanced primary care management services, global surgery payment, behavioral health services, dental services, preventive services, such as colorectal cancer and hepatitis B screening, and Inflation Reduction Act provisions relating to Part B drugs and biologicals. The proposed rule contains several comment solicitations, including on services addressing health-related social needs, building upon the MIPS Value Pathways framework to improve ambulatory specialty care, and strategies for implementing recurring updates to direct and indirect practice expense.

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An Explanation of Final Medicaid Managed Care and Access Rules

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In This Report:

Executive summary.

While the Centers for Medicare & Medicaid Services (CMS) has overseen the steady growth in Medicaid coverage over recent years, CMS has faced the additional challenges of ensuring that coverage truly leads to meaningful access to care and that there is strong oversight. CMS recently finalized two key regulations: “ Ensuring Access to Medicaid Services ” (Access Rule) and “ Medicaid, CHIP Managed Care Access, Finance, and Quality ” (Managed Care Rule), which represent the latest steps in CMS’s iterative process aimed at improving access to care and oversight in Medicaid and CHIP across delivery systems (fee-for-service and managed care). The Access Rule addresses three primary areas: documentation of access to care and service payment rates, stakeholder and enrollee advisory committees, and home and community-based services. The Managed Care Rule addresses five primary areas: access in managed care, including network adequacy; state directed payments; medical loss ratio standards; in lieu of services and settings; and quality and performance assessment. Once fully implemented, the rules will make meaningful improvements in access to care, data and payment transparency, and beneficiary engagement.

The timeline for implementation of the Access and Managed Care Rules extends over the next several years, but when fully implemented, these rules will give stakeholders more tools to hold state Medicaid agencies and managed care plans accountable for the accessibility and quality of care in Medicaid and CHIP.

This brief summarizes both rules across the following key topics:

• Increasing enrollee and stakeholder engagement by expanding the scope of states’ Medicaid Advisory Committees, requiring states to establish Beneficiary Advisory Councils and Interested Parties Advisory Groups, and capturing managed care enrollee experiences through an annual survey;
• Improving access to care in managed care by establishing maximum appointment wait time standards and requiring states to use independent secret shopper surveys to verify managed care plan compliance with such standards and the accuracy of provider directories;
• Requiring more payment transparency to drive better payment adequacy including posting fee-for-service payment schedules, comparing fee-for-service payment rates to Medicare rates, comparing managed care rates to fee-for-service rates, disclosing home and community-based service payment rates, setting minimum performance rates for direct care workers, and revamping the CMS review process for rate reductions;
• Increasing transparency and oversight of state directed managed care payments and allowing targeted flexibilities to increase access to a broader range of Medicaid services in lieu of traditional services/settings;
• Advancing quality by reducing reporting lag times, moving towards a managed care quality rating system that will provide plan-level performance data to the public, and advancing home and community-based services quality measurement and reporting;
• Improving the availability of information and resources to support enrollees and choice counselors in making health care decisions, including improving website navigability; and
• Enhancing transparency and monitoring of home and community-based services .

Introduction

Medicaid and the Children’s Health Insurance Program (CHIP) provide health insurance coverage to more than 80 million people, including low-income children, families, seniors, pregnant people, and people with disabilities. [1] While Medicaid has a proven track record of providing affordable, high quality health care, stakeholders have long sought better transparency and accountability with respect to access to services. [2] The Centers for Medicare & Medicaid Services (CMS) recently finalized two key regulations: “Ensuring Access to Medicaid Services” (Access Rule) [3] and “Medicaid, CHIP Managed Care Access, Finance, and Quality” (Managed Care Rule), [4] aimed at improving access to care in Medicaid across delivery systems (fee-for-service (FFS) and managed care) and authorities (state plan and waiver services).

Most Medicaid beneficiaries (74 percent in 2021) in most states are enrolled in comprehensive, risk-based managed care. [5] But despite the large and growing role Medicaid managed care organizations (MCOs) play, monitoring FFS systems continues to be important even in states with high managed care penetration rates given the role FFS plays in delivering care to people in rural areas and people with complex medical needs. Similarly, most Medicaid benefits are provided through the state plan benefit package, but home and community-based waivers and section 1115 demonstration waivers serve an outsized role for particular beneficiary groups (e.g., people with disabilities, people with behavioral health needs, etc.). Thus, it is important that strategies to improve access to care apply regardless of the delivery system or statutory authority under which they operate. Once fully implemented, the rules will make meaningful improvements in access to care, data and payment transparency, and beneficiary engagement.

Effective Dates

Throughout the Access and Managed Care Rules, the applicability dates are often described as beginning on the first rating period after a specified effective date (e.g., first rating period beginning on or after July 9, 2024). Most states set their managed care contracts on either a January 1 – December 31 or July 1 – June 30 basis, though some states use September 1 or October 1 start dates. This means that, for example, in a state using a July 1 – June 30 contract year, provisions taking effect “on the first rating period on or after July 9” of a given year will actually take effect on July 1 of the following year. For more details about the specific applicability dates of each provision, see the Appendix and CMS’ applicability date charts available at  https://www.medicaid.gov/medicaid/access-care/downloads/applicability-date-chart-ac.pdf  and  https://www.medicaid.gov/medicaid/managed-care/downloads/applicability-date-chart-mc.pdf .

[Note: Some provisions apply to Medicaid only whereas others apply to Medicaid and separate CHIP. Similarly, some provisions apply to FFS delivery systems, whereas others apply to managed care or both FFS and managed care. The applicability of each section is noted in italics below the heading .]

Enrollee and Stakeholder Engagement

The Access and Managed Care Rules make a number of important changes to improve enrollee and stakeholder engagement. The rules update the Medical Care Advisory Committee (MCAC) requirements and create two new advisory committees, which will include individuals enrolled in Medicaid and will provide recommendations to state Medicaid agencies. The rules will also require surveys of managed care enrollees to inform plan performance improvement and support better person-centered HCBS planning. These new provisions should help empower individuals in Medicaid to leverage their experience for program improvement.

Establishes Medicaid Advisory Committee and Beneficiary Advisory Council (§ 431.12)

[Medicaid; FFS and managed care]

  Medicaid has long-standing requirements for states to operate MCACs, stakeholder advisory committees that include individuals enrolled in Medicaid and provide the state Medicaid agency with recommendations on how to run its program. The Access Rule makes two overarching changes to the current MCAC structure. First, the MCAC is renamed “Medicaid Advisory Committee” (MAC) and numerous new details and standards are set out for MACs. Second, the rule creates a new parallel entity, the Beneficiary Advisory Council (BAC), which will also provide direct advice to the state Medicaid agency and some BAC members will also serve on the MAC. Once fully implemented, the rule will require at least 25 percent of MAC membership be comprised of BAC members.

The Access Rule specifies that BAC members can be individuals enrolled in Medicaid (including youth), as well as their families and caregivers. In addition to including BAC members, the MAC membership must include at least one of each: a consumer advocacy organization, a provider group, a managed care entity, and one other relevant state agency (the state agency is in a non-voting role). The rule requires MACs and BACs to meet at least quarterly, with at least two MAC meetings open to the public each year. BACs can choose whether their meetings are public. The Access Rule sets out important requirements for MACs and BACs, including developing bylaws and publicly posting them along with formal processes for appointing members, meeting schedules, past meeting minutes, and attendee lists (BAC members can opt out of being named in minutes and attendee lists). Under the rule, the MAC will also produce an annual report, which must be publicly posted, detailing recommendations made to the state and state responses.

The rule also expands the requirements for states to support MAC and BAC members to promote their participation. This includes financial support, which CMS clarifies includes at least reimbursement for travel, lodging, meals, and childcare when “necessary.” While broader financial support such as stipends are permissible, CMS notes they may impact countable income for eligibility purposes (expense reimbursements do not impact eligibility). Importantly, the rule also requires states to provide “research or other information needed” to support MAC and BAC members. Finally, the rule requires states to ensure that meetings are accessible (including disability and language) and that meeting times and locations are selected and varied to maximize member attendance. Effective date: The new standards for MACs and BACs take effect July 9, 2025, though the requirement to ensure 25 percent of MAC membership comes from the BAC is phased in over a three-year period.

HCBS Interested Parties Advisory Group (§ 447.203(b)(6))

[Medicaid; FFS]

  The Affordable Care Act (ACA) requires the Secretary of Health and Human Services (HHS) to issue regulations to ensure that all states develop service systems that support home and community-based (HCBS) services. [6] This includes improving coordination and regulation of providers to oversee and monitor functions to assure, among other requirements, an adequate number of qualified direct care workers to provide self-directed services. Such requirements continue to be important given ongoing access issues for direct care workers in Medicaid. [7] In addition, because Medicare generally does not cover such services, states are limited in their ability to compare payment rates to Medicare rates when considering whether payment rates are hindering access.

With the Access Rule, states will be required to establish an Interested Parties Advisory Group (IPAG) to advise and consult on fee-for-service (FFS) rates paid to direct care workers providing self-directed and agency-directed services for personal care, home health aide, homemaker services, and habilitation services provided under §§ 1905(a), 1915(i), (j), (k) state plan authorities, section 1915(c) waivers, and where applicable, 1115 demonstrations. Under the rule, the IPAG will advise and consult with the state Medicaid agency on current and proposed payment rates, HCBS payment adequacy data, and access to care metrics to ensure Medicaid payment rates are sufficient to ensure access to the selected services including a sufficiently large workforce to maintain access to services. [8] The IPAG is required to meet by July 2026 and at least every two years thereafter and include, at a minimum, direct care workers, beneficiaries and their authorized representatives and other interested parties which could include beneficiary family members and advocacy organizations. States have flexibility over member tenure, conflict of interest policies, and general operation, including whether and how the IPAG may intersect with MACs; however, the process by which a state selects IPAG members and convenes meetings must be made publicly available. Recommendations of the IPAG must also be made public within one month of being provided to the state Medicaid agency. Finally, the rule also requires states to ensure the group has access to current and proposed payment rates, available HCBS provider payment adequacy minimum performance and reporting standards, and applicable access to care metrics to make recommendations and to consider and respond to recommendations on proposed rate changes; however, the rule reiterates that recommendations are non-binding on the state and not required in advance of every state rate change. Effective date: The first meeting must be held by July 9, 2026, with subsequent meetings at least every two years thereafter.

Enrollee Experience Surveys (§§ 438.66(b)(4) and (c)(5), 457.1230)

[Medicaid and CHIP; managed care]

One measure of access to care in an MCO is the experience of its enrollees as reported by enrollees themselves. [9] Under current regulations, state Medicaid agencies must use the results of any enrollee or provider satisfaction survey, whether conducted by the agency or the MCOs, in improving the performance of their managed care programs. They are not, however, required to conduct those surveys or to post the results. Nor are they required to conduct enrollee experience surveys, which focus not on whether an MCO or its providers have met the enrollee’s expectations, but on whether something that should happen in an MCO, such as timely access to a physician or effective care coordination, actually happened.

The Managed Care Rule requires state Medicaid agencies to conduct, on an annual basis, an enrollee experience survey, and to use those results in improving the performance of their managed care programs. Section 438.358(c)(2) of the rule makes clear that state agencies, at their option, can use an External Quality Review Organization (EQRO) to conduct these surveys. In § 438.10(d)(2) the rule does not specify the survey instrument that state agencies must use but requires that whatever instrument the state selects meets the interpretation, translation, and tagline criteria so that the survey and the results are easy for enrollees to read and understand. The rule also requires state Medicaid agencies to include an evaluation of MCO performance that is based on the results of the annual enrollee experience survey in the Medicaid and CHIP Annual Program Report (MCPAR) they submit to CMS each year (and post on their own websites), as required by § 438.66(e)(2)(vii ). Effective date: These requirements will take effect for contract rating periods beginning on or after July 9, 2027 .

The rule applies similar new requirements to states with separate CHIP programs that contract with MCOs (as of March 2023, 27 states did so). [10]   In analyzing the adequacy of MCO networks, these states will be required to evaluate the results of the most recent annual survey of enrollee experience.  Under § 457.1207, states will also be required to post on their state Medicaid agency website comparative summary results of enrollee experience surveys specific to each MCO with which they contract. Effective date: This requirement is effective July 9, 2026.

HCBS Person-Centered Service Plans (§§ 441.301(c)(1) and (3), 441.311(b)(3), 441.450(c), 441.540(c), 441.725(c))

The Medicaid statute requires that HCBS services provided through a section 1915(c) waiver be provided pursuant to a written plan of care referred to in the Access Rule as a person-centered service plan or service plan. Previous regulations and guidance included a number of requirements related to person-centered service plans and state compliance, however, as noted in the rule, based on feedback from advocates, states, and others, there continues to be a need to standardize reporting and set minimum standards for HCBS, including ensuring necessary revisions to person-centered service plans in order for individuals receiving HCBS to remain as independent as possible and prevent adverse outcomes. [11]

Accordingly, the Access Rule sets forth a new approach to person-centered planning requirements. Under the rule, the state must ensure that every individual’s person-centered service plan is reviewed and revised at least annually, when the individual’s circumstance changes significantly, or upon request. States must: (1) complete a reassessment of functional need at least every year and (2) review and revise, as appropriate, the person-centered service plan based upon the reassessment of functional need for no less than 90 percent of individuals by July 2027 for FFS delivery systems and by the first rating period beginning after that date for managed care delivery systems. In demonstrating compliance, states must report annually to CMS on the percentage of individuals who had a reassessment of functional need completed within the past 12 months and the percentage who had their service plan updated as a result of that reassessment, which they may do through the use of statistically valid random samples. The rule applies these requirements to HCBS provided under 1915(c) waiver programs and 1915(i), (j), and (k) state plan services in accordance with the ACA requirement for states to improve coordination and regulation of HCBS services. [12] However, the requirements do not apply to HCBS delivered under 1905(a) state plan authorities, although the rule recommends states implement person-centered planning processes for all HCBS. Effective date: States must comply with the person-centered 90 percent performance levels by July 9, 2027 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date .

Access to Care

The Managed Care Rule contains a number of provisions intended to ensure that MCO enrollees have access to the services they need and to which they are entitled.  When fully implemented over the next five years, these provisions will make provider directories more useful to enrollees and establish minimum standards for appointment wait times. State agencies will be required to monitor compliance through secret shopper surveys.  In the event of noncompliance, enforcement tools will include remedy plans.

The Access Rule increases the amount of information state Medicaid agencies report to CMS relating to their HCBS waiver programs.  The new data relates to waiting lists, wait times for services, and the percentage of authorized hours for services actually received.  When reporting begins in three years, this information will give CMS and stakeholders greater visibility into the accessibility of HCBS services, whether delivered on a FFS basis or through an MCO.

Provider Directories (§ 438.10(h))

[Medicaid; managed care]

If Medicaid enrollees do not have accurate and current information about which providers are participating in an MCO’s network, they cannot make an informed choice about which MCO will best meet their needs. Currently MCOs are required to post provider directories on their websites, to make them available to enrollees, upon request, in paper form, and to update them regularly. The directory must provide information for at least the following types of providers: physicians, hospitals, pharmacies, and behavioral health providers. For each provider the directory must include the following information: name, specialty, street address, telephone number, language capabilities, accommodations for patients with physical disabilities, and whether the provider will accept new enrollees.

These requirements proved insufficient to protect enrollees from “phantom” provider networks, so Congress revised and codified them in section 5123 of the Consolidated Appropriations Act, 2023. [13] The Managed Care Rule implements these revisions. To make the provider directories more useful to enrollees, each MCO will be required to make its directory available in searchable electronic form. In addition to the information about each provider specified in current regulation, the directories must also indicate whether the provider offers covered services via telehealth and must distinguish mental health and substance use disorder providers. Shortly after releasing the rule, CMS issued a State Health Official Letter that outlines more details about the provider directory requirements. [14] To ensure the accuracy of MCO provider directories, the rule provides for secret shopper surveys. For more detail, see below. Effective dates: These new requirements apply July 1, 2025. In addition, state Medicaid agencies are required to post provider directories on their websites beginning July 1, 2026.

Appointment Wait Time Standards (§§ 438.68(e), 457.1218)

Under current regulations, state Medicaid agencies must develop quantitative network adequacy standards for each of seven different provider types, including primary care, obstetrics/gynecology (OB/GYN), behavioral health, specialist, hospital, pharmacy, and pediatric dental. In the case of primary care, behavioral health, and specialist services, the standards must distinguish between adults and children. The regulations do not specify the quantitative standards that states must use; as a result, there is wide variation from state to state. [15]

The Managed Care Rule builds out from this. It continues the requirement under § 438.68(b)(1) that state Medicaid agencies develop a quantitative network adequacy standard for each of seven different types of providers. In addition, the rule requires state Medicaid agencies to “establish and enforce” appointment wait time standards for specific services. For routine primary care (adult and pediatric) or OB/GYN visits, appointment wait times cannot exceed 15 business days from the date of request. For routine visits for outpatient mental health and substance use disorder (adult and pediatric), the standard is 10 business days from the date of request. State Medicaid agencies may establish shorter timeframes.

The rule defines compliance with these standards for routine appointments as “a rate of appointment availability … of at least 90 percent.” That is, at least 90 percent of the requests for routine appointments result in appointments within the 10- or 15-day standard (or state-specified standard, if shorter). Whether individual MCOs meet this compliance standard will be determined by an annual secret shopper survey (see below). State Medicaid agencies will have discretion to define what constitutes a “routine” appointment. Under § 438.68(d), state agencies will also be able to grant an MCO an exception to these requirements based on the number of providers in the specialty practicing in the MCO’s service area, taking into consideration the payment rates that MCO offers. These requirements apply to separate CHIP programs by an existing cross reference at § 457.1218. Effective date: These requirements will take effect for contract rating periods beginning on or after July 9, 2027 .

Secret Shopper Surveys (§§ 438.68(f), 457.1218)

The rule’s new requirements relating to provider directories and appointment wait times will be meaningful only to the extent that MCOs comply. To monitor compliance, the rule turns to secret shopper surveys. While many state Medicaid agencies already use secret shopper surveys to help monitor MCO compliance with network adequacy requirements, [16] there is no requirement in current regulations that they do so. The rule changes this policy. It requires state Medicaid agencies to contract with an independent entity to conduct annual secret shopper surveys of each MCO’s compliance with: (1) the provider directory requirements and (2) appointment wait time standards.

Under the rule, the entity conducting the secret shopper survey must be independent of both the state Medicaid agency and the MCO subject to the survey. For purposes of assessing compliance with both the provider directory and appointment wait time requirements, the surveys must use a random sample and must include all areas of the state served by the MCO. In addition, for appointment wait time standards, the secret shopper survey must be completed for a statistically valid sample of providers. State agencies must report the results of the surveys to CMS and post them on their websites within 30 days of submission to CMS. These requirements apply to separate CHIP programs by an existing cross reference at § 457.1218. Effective date: These requirements will take effect for contract rating periods beginning on or after July 9, 2028 .

Remedy Plans (§§ 438.207(f), 457.1230(b))

Establishing new access standards for MCOs, and monitoring MCO compliance with those standards, is necessary to improving enrollee access to care, but they are not sufficient. Enforcement of MCO compliance is needed as well. Currently, CMS regulations require state Medicaid agencies to submit corrective action plans when they identify deficiencies in access to care in FFS Medicaid programs (the new Access Rule retains this provision). There is no comparable enforcement mechanism for access deficiencies in managed care Medicaid. (CMS has general authority to withhold federal matching funds in order to ensure compliance by states with federal Medicaid requirements, but the use of this authority by CMS is extremely rare.)

The Managed Care Rule establishes a new enforcement mechanism to remedy access problems in managed care: remedy plans. If either the state Medicaid agency or CMS “identifies an area in which an MCO’s … access to care under the access standards … could be improved,” the state Medicaid agency will be required to submit a remedy plan to CMS for approval. The remedy plan must “address” the identified access issue within 12 months, and the state agency must submit quarterly updates on the progress of implementation to CMS. If the remedy plan does not improve access within 12 months, CMS may require the state to continue the plan for another 12 months. No further consequence is specified. These provisions apply to separate CHIP by cross reference at § 457.1230(b). Effective date: These requirements will take effect for contract rating periods beginning on or after July 9, 2028.

HCBS Access Reporting (§§ 441.303(f)(6), 441.311(b)(4), 441.311(d)(1), 441.311(d)(2))

The majority of states employ HCBS waivers, which allow them to offer a wider range of benefits but also limit the number of people who receive services. [17] In addition, even when individuals are approved for HCBS, many often struggle to find staff to support them. As noted in the Access Rule, there is a need to improve public transparency and processes related to states’ HCBS waiting lists and standardized reporting, including timeliness of HCBS and the share of services individuals are eligible for versus services that are received. [18]

Under the rule, states must report to CMS annually on HCBS waiver waiting lists. For states that have a limit on the size of the waiver program and maintain a list of individuals who are waiting to enroll, states must report the number of people on the list and the average amount of time individuals newly enrolled in the waiver program in the past 12 months were on the waiting list. States must also report on whether the state screens individuals for eligibility prior to placing them on the list, whether the state periodically screens individuals on the list for continued eligibility, and the frequency of rescreening, if applicable. The requirement applies to 1915(c) waiver programs, 1915(j) where applicable, and 1115(a) demonstrations if they include an HCBS enrollment cap.

In addition, the rule also requires states to report to CMS annually on the average amount of time from when homemaker services, home health aide services, personal care services, and habilitation services are initially approved to when services begin for individuals newly receiving such services within the past 12 months. States must also report annually on the percent of authorized hours for such services that were provided within the past 12 months. The reporting requirements apply to such services authorized under section 1915(c), 1915(j), (k) and (i) authorities and 1115 demonstration programs (unless explicitly waived), but not 1905(a) state plan authority, delivered under both FFS and managed care delivery systems as well as self-directed services. States may use a statistically valid random sampling of individuals to report the data. Effective dates: States must come into compliance with the HCBS waiting list reporting requirement and the reporting on wait times and authorized service hours for the selected services by July 9, 2027 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date .

Finally, the rule amends existing 1915(c) HCBS waiver reporting expectations to avoid duplicate or conflicting reporting requirements. Under this requirement, annually and in the form, manner, and time specified by CMS, states must provide information on the waiver’s impact on the type, amount, and costs of services provided under the state plan. Effective dates: July 9, 2027 for FFS, and in the case of managed care, for contract rating periods beginning on or after that date .  

Provider Payment

Federal law entitles Medicaid beneficiaries to medical assistance , defined under section 1905(a) of the Social Security Act (the Act) as, “payment of part or all of the cost of the following care and services or the care and services themselves, or both”. Section 1902(a)(30)(A) of the Act requires that Medicaid state plans ‘‘assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area’’ (emphasis added). Fulfilling these obligations necessitates CMS to require sufficient provider payments to ensure beneficiaries have access to care. These standards are important to assure that people with low-incomes who are enrolled in Medicaid can access care and services they need to get and stay healthy.

The Access and Managed Care Rules include various provisions aimed at improving payment rate transparency, such as requiring states to post FFS payment rate schedules, compare Medicaid FFS payment rates to Medicare rates, disclose HCBS payment rates to allow for comparisons over time and between states, and report aggregate provider payment rates under managed care compared to what the state would have paid under FFS. Taken together, these provisions will result in significantly more publicly available payment rate data that can inform future payment rate changes.

Fee-for-Service Rules in a Managed Care State

As noted, most Medicaid beneficiaries in most states are enrolled in managed care. However, all states have Medicaid FFS fee schedule payment rates in effect and are therefore subject to the rules described below under § 447.203(b), regardless of the quantity of services covered or delivered or number of beneficiaries enrolled in managed care. Even states that generally enroll all beneficiaries into managed care plans pay for some services on a FFS basis that are not covered under the plan contract. For example, during coverage transition periods, such as when an individual is Medicaid eligible but not yet enrolled in a managed care plan, or during periods of retroactive coverage.

FFS Payment Rate Transparency (§ 447.203(b)(1))

Under access regulations finalized in 2015, states are required to develop and submit to CMS an Access Monitoring Review Plan (AMRP) for certain Medicaid services. The AMRP must separately analyze access to: primary care services (including those provided by a physician, FQHC, clinic, or dental care), physician specialist services (for example, cardiology, urology, radiology), behavioral health services (including mental health and substance use disorder), pre- and post-natal obstetric services including labor and delivery, and home health services, along with three types of “additional services,” those subject to a rate reduction, those for which the state or CMS has received a lot of complaints, and any additional services selected by the state.

The Access Rule rescinds the AMRP requirements and implements a new regulatory framework for access monitoring including improved rate transparency and analysis. Under the new rule, states must post Medicaid FFS payment rates on a publicly available website by July 1, 2026. Medicaid FFS payment rates must be organized in such a way that a member of the public can readily determine the amount Medicaid would pay for a given service. Rates must be provided separately for adults and children if they vary by population. The preamble to the rule emphasizes that the posting requirement is limited to fee schedule payment rates that are known in advance of a provider delivering a service . [19] Payments made by statutory formula (e.g., prospective payment rates made to federally qualified health centers (FQHCs), rural health clinics (RHCs), and certified community behavioral health clinics (CCBHCs)) and cost-based payments are excluded. Bundled payments are included in the transparency requirements, but states must provide a breakdown of the constituent parts only if each component is based on a fee schedule payment rate.

CMS issued a companion guide with an example of these rate transparency requirements and how to handle payment bundles shortly after issuing the final rule. [20] Effective date: July 1, 2026, though states are no longer required to comply with AMRP requirements as of July 9, 2024.

FFS Payment Rate Analysis and Disclosure (§ 447.203(b)(2)-(5))

In addition to requiring states to post FFS payment fee schedules, the Access Rule requires states to compare base Medicaid FFS rates to Medicare rates for primary care, OB/GYN services, and outpatient mental health and substance use disorder services. Rates must be compared at the code level and must include any beneficiary copayment amounts but exclude supplemental payments. If the rates vary based on provider type, adult versus pediatric patients, or geographic location, separate reporting is required. States must post the Medicaid rate, the Medicare rate, the Medicaid rate as a percentage of the Medicare rate, the number of Medicaid-paid claims and the number of people enrolled in Medicaid who received the service within the calendar year. CMS posts the Medicare rates needed for this analysis annually in the Medicare Physician Fee Schedule. The companion guide noted above details these requirements and outlines how to conduct the payment analysis. [21] Effective date: July 1, 2026 (comparing 2025 rates) and every two years thereafter.

For certain HCBS services (personal care, home health aide, homemaker, and habilitation services), states are required to disclose the Medicaid payment amount for 2025 by July 1, 2026 and every two years thereafter. States are required to disclose the Medicaid payment amount expressed as an average hourly rate regardless of whether the state actually pays for such services on an hourly, daily, or other basis, in order to allow for comparison over time and between states. Like the payment analysis, if the rates vary based on provider type, adult versus pediatric patients, or geographic location, the rates must be separately disclosed. Unique to the HCBS payment rate disclosure, states must identify whether the payment rate includes facility-related costs. Effective date: July 1, 2026.

HCBS Payment Transparency and Adequacy (§§ 441.311(e) and 441.302(k)(3))

HCBS payment rates must be adequate to ensure a sufficient direct care workforce to meet the growing demand for high-quality HCBS care, and yet, HCBS rate increases have not always resulted in corresponding higher wages for HCBS direct care workers. Under § 441.311(e) of the Access Rule, in both FFS and managed care delivery systems, states will be required to report annually on the share of Medicaid payments for homemaker services, home health aide services, personal care, and habilitation services that goes to direct care worker compensation, or the “compensation percentage.” The state must report separately for each service, and within each service, must separately report services that are self-directed and services that are delivered in a provider-operated physical location for which facility costs are included in the payment rate. The rule does not require these reports to be posted publicly. Effective date: The reporting requirement is effective as of July 9, 2028 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date .

In addition to this broad reporting requirement, the Access Rule requires that states meet a minimum performance payment adequacy requirement for some direct care workers under § 441.302(k)(3). Specifically, states will be required to provide assurances to CMS that each home care provider spends 80 percent of total payments on compensation for direct care workers who furnish homemaker, home health aide, or personal care services (this “80 percent rule” does not apply to habilitation services which are subject to the reporting requirement above). States may set a lower threshold for “small” providers, as defined by the state, as long as the criteria for defining “small” and the performance percentage are reasonable, objective, and developed through a transparent process. States may also develop a hardship exemption for providers of any size that are facing “extraordinary circumstances that prevent their compliance” with the 80 percent rule. States that take advantage of these flexibilities must report to CMS annually on the criteria developed, the percentage of providers impacted, and the plan for improved performance in the future. Effective date: The HCBS payment adequacy provision is effective July 9, 2030 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date .

FFS Rate Reductions (§ 447.203(c))

Under current regulations, as part of the CMS approval process for rate reductions or restructuring in FFS, states must analyze access to services subject to the rate reduction, consider the data collected through the AMRP, and undertake a public process that solicits input on the potential impact of the proposed changes. As noted above, the Access Rule eliminates the AMRP process and implements new payment transparency and analysis requirements. For rate reductions, the Access Rule establishes a two-tiered approach: CMS will use a lower level of review for rate reduction/restructuring state plan amendments (SPAs) that satisfy certain criteria and a higher level of review with enhanced analysis requirements for those SPAs that do not meet the criteria.

To satisfy tier one, states must provide CMS with written assurance and relevant supporting documentation to establish that: (1) services affected by the proposed rate reduction or restructuring would be paid at or above 80 percent of the most recently published Medicare rates for the same or comparable aggregate set of Medicare-covered services; (2) the proposed rate reductions or restructurings would result in no more than a four percent reduction in aggregate FFS expenditures for each benefit category within a single state fiscal year; and (3) the public processes set out in §§ 447.203(c)(4) and 447.204 yielded no significant access concerns, or if such process did yield concerns, the state can reasonably respond to or mitigate them. The state must also describe the procedures for monitoring continued compliance with section 1902(a)(30)(A) of the Act.

A SPA that proposes to reduce or restructure payment rates and fails to meet the criteria for tier one is subject to additional review. To satisfy tier two, in addition to providing the information above, states must summarize the payment rate change; compare the aggregate payment rates before/after the proposed change to Medicare, and other payers if feasible; describe trends in the number of actively participating providers, beneficiaries served, and services delivered in each affected benefit category over the past three years; and summarize the state’s response to any access to care concerns received from beneficiaries, providers, and other interested parties regarding the affected services.

States must have ongoing mechanisms for beneficiary and provider input on access to care, but neither the state nor CMS are required to post the SPA or supporting documentation for tier one or tier two. CMS may disapprove SPAs if states fail to comply with these analysis requirements. Effective date: SPAs submitted on or after July 9, 2024.

Managed Care Payment Rate Analyses and Reporting (§§ 438.207(b) and (d), 457.1230(b))

Current regulations require that each MCO, prepaid inpatient health plan (PIHP), and prepaid ambulatory health plan (PAHP) provide to the state Medicaid agency documentation that demonstrates that it maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. The state agency, in turn, is required to submit to CMS an analysis that supports the assurance of the adequacy of the network of each MCO, along with supporting documentation.

The Managed Care Rule requires that each MCO, PIHP and PAHP submit a “payment analysis” to the state Medicaid agency that compares the total amount paid by the plan for evaluation and management (E&M) codes for primary care, OB/GYN, mental health, and substance use disorder services during the prior rating period with the total that would have been paid by the plan if the plan had used published Medicare payment rates for those services. These rules echo the FFS payment analysis requirements, but the managed care payment analyses will be conducted on an aggregate basis. For certain long term care services that Medicare does not cover, such as homemaker, home health aide, personal care, and habilitation services, the analysis must provide the total amount paid and the percentage that results from dividing the total amount paid by the amount the state’s Medicaid FFS program would have paid for the same services. If the percentages differ between adult and pediatric services, they must be reported separately.

The state agency, in turn, is required to include these payment analyses in the annual analysis it must submit to CMS and to post its analysis on the state agency’s website within 30 calendar days of submission. These requirements apply to separate CHIP programs by cross reference at § 457.1230(b), except that states must submit the Medicaid analyses to CMS in advance of CMS’ review and approval of the Medicaid managed care contract. Effective dates: These payment rate analyses requirements will take effect for contract rating periods beginning on or after July 9, 2026, but most states must post an assurance of compliance with adequate capacity and services for contract rating periods beginning on or after July 9, 2025. 

Managed Care Payment

The Managed Care Rule includes several technical, but important, revisions to managed care payment policies. The primary overarching theme to these provisions is building transparency and oversight to managed care payments to better understand how capitation dollars are being spent and help ensure managed care delivers value. A second and important theme is building targeted flexibilities to allow payment to improve access to care, including access to a broader range of Medicaid services.

State Directed Payments (§§ 438.6, 438.7, 430.3)

In Medicaid managed care delivery systems, the state Medicaid agency is generally prohibited from directing how MCOs, PIHPs, and PAHPs, pay their network providers. However, in 2016 CMS formally established a regulatory exception allowing states some limited power over how managed care plans pay providers, known as “State Directed Payments” (SDPs). Under an SDP, for example, states have been allowed to require managed care plans to use a minimum or maximum fee schedule, set a uniform payment increase for selected providers, participate in multi-payer models, or use a value-based purchasing method. States can use this authority to improve rates for targeted providers (i.e., for example, when access problems are identified) or to more generally support health care infrastructure. Most SDP funding has gone to hospitals, but states have also used SDPs to support access to mental health, substance use disorder treatment, and dental care. [22] Depending on the design of the SDP arrangement, it may have a streamlined or more complex approval process. Under the Managed Care Rule, states have a new option for streamlined SDPs: they can require managed care plans to pay providers using Medicare rates.

In response to the rapid growth in SDP spending across states, the new rule also increases oversight over SDP spending. Starting September 2024, states must include SDP spending data in medical loss ratio (MLR) reporting. In addition, after CMS develops reporting instructions, states will have to report provider-specific data annually through the Transformed Medicaid Statistical Information System (T-MSIS), allowing CMS to track how much money is flowing to which providers. States will also be required to submit evaluation reports for most types of SDPs when they amount to more than 1.5 percent of managed care program costs. States will be required to publicly post the evaluations, and CMS has committed to posting them as well. The rule will allow some managed care SDP payments to go as high as the Average Commercial Rate (ACR), which is often well above Medicaid and Medicare rates. This creates misalignment with FFS supplemental payments, which are generally capped at Medicare payment levels. In the rule, CMS also opted not to set caps for total SDP spending.

Finally, in the preamble to the rule, CMS clearly reiterates that provider taxes, a critical source of state funding for SDPs, remain a permissible tool for financing the state share of SDPs. [23] However, the rule will require states to collect compliance attestations from taxed providers, which could make it harder for states to implement provider taxes. CMS issued an Informational Bulletin parallel to the new regulations indicating it will be working collaboratively with states between now and 2028 to help them come into compliance with the new provider tax requirements. [24] Effective dates: Streamlined option for SDP using minimum Medicare fee schedule, July 9, 2024; SDP reporting in MLR reports, September 9, 2024; SDP reporting in T-MSIS,  no later than the date specified in the T–MSIS reporting instructions released by CMS ; SDP evaluation reports, contract rating periods beginning on or after July 9, 2027; SDP caps as high as ACR, contract rating periods beginning on or after July 9, 2024; provider tax compliance attestations, contract rating periods beginning on or after  January 1, 2028 . 

In Lieu of Services (§§ 438.2, 438.3, 438.7, 438.10, 438.16, 438.66, 457.1201, 457.1207)

Medicaid managed care plans have long covered “In Lieu of Services” (ILOS), which are services that are provided in substitution of traditional Medicaid state plan services. For example, an MCO might provide a community-based depression screening in lieu of an office visit screening. ILOS are important because, unlike other non-traditional services a managed care plan may choose to provide, ILOS are factored into rate setting, thus giving managed care plans a stronger incentive to provide the services. CMS formally defined ILOS for the first time in 2016 regulations. Recently, interest has grown in ILOS as a mechanism to cover services to meet health-related social needs.

Historically, the use of ILOS was constrained to substitution services that were direct and immediate substitutions. CMS’s new rule modifies the definition of ILOS to explicitly include services that are “an immediate or longer-term substitute for a covered service or setting” or that “can be expected to reduce or prevent the future need to utilize the covered service or setting.” [25] This broader definition will allow states to make investments in services that address prevention or health-related social needs that go beyond the traditional state plan services. For example, a state might cover medically-tailored meals for individuals with diabetes to reduce (or “substitute” for) emergency room or hospital use.

The new rule also codifies protections for individuals enrolled in Medicaid accessing ILOS. These include requirements that:

• Individuals accessing ILOS have all rights and protections that apply to traditional Medicaid managed care services (including appeals rights);
• Individuals retain the right to receive state plan services, regardless of being offered, using, or previously using ILOS;
• ILOS may not be used to discourage access to state plan services;
• Plans must describe these protections in enrollee handbooks; and
• States must include these requirements in plan contracts.

Finally, the rule also increases oversight and control over ILOS spending. States will be required to document the details and eligibility criteria for the ILOS they are providing and ensure they have clearly identifiable codes in encounter data. In addition, states will be required to submit a series of reports summarizing their projected and actual spending on ILOS, including one based on actual claims and encounter data. States will have documentation and evaluation reporting requirements when projections or spending exceeds 1.5 percent of capitation and they will be subject to a five percent cap on total ILOS spending. The new ILOS requirements are generally applicable to separate CHIP by cross references at §§ 457.1201 and 457.1207, with some exceptions (e.g., excluding from CHIP references that are inapplicable such as actuarial certification and SDPs). Effective dates: Expanded definition of ILOS and enrollee protections, contract rating periods beginning on or after July 9, 2024; oversight requirements, contract rating periods beginning on or after September 9, 2024.

Medical Loss Ratio Standards (§§ 438.8, 438.3, 457.1203)

An MLR is a measure of how much of the capitation payments to a plan goes toward providing Medicaid services to enrollees and improving quality, as opposed to administration and profit. Current Medicaid regulations require plans to submit annual MLR reports to states, and states to in turn submit an annual “summary description” of the MLR reports to CMS. The rule clarifies that the summary description must be provided for each plan under contract with the state and also requires MLR reporting to factor in SDP spending. In addition, the rule clarifies how provider incentive arrangements and bonus payments are counted in the MLR calculation. The updates to the MLR requirements apply to separate CHIP by existing cross reference at § 457.1203, though the final rule makes some technical changes to clarify that the SDP-related provisions do not apply to separate CHIP. Effective dates: Plan level MLR reporting and inclusion of SDPs in MLR reporting, September 9, 2024; provider incentive arrangement policies, contract rating periods beginning on or after July 9, 2025.

Medicaid Quality Systems and Reporting

  The Managed Care Rule makes significant improvements to managed care quality requirements, including boosting transparency and reducing reporting lag times. When fully enacted, these changes will transition states from reporting a single overall quality rating for a managed care plan to rating all mandatory measures individually for each plan. Apart from eliminating primary care case management (PCCM) entities from inclusion with other types of MCOs, the rule adopts the provisions of the proposed rule [26] with minor changes for organizational clarity. The rule also sets forth a formal process for the HCBS quality measure development and requires states to use and report on the HCBS Quality Measure Set.  

Managed Care State Quality Strategy (§§ 438.340, 457.1240(d))

The managed care state quality strategy is a foundational tool for states to set goals and objectives relating to the quality of care and access for managed care programs. Under prior regulations, each state contracting with MCOs was required to implement a written quality strategy for assessing and improving the quality of health care services furnished by an MCO, PIHP, or PAHP. The new rules increase opportunities for interested parties (e.g., health care providers and consumer advocates) to provide input on the state’s managed care state quality strategy prior to CMS review. The strategy must be reviewed every three years or whenever significant changes occur within the state’s Medicaid program. States must post the full evaluation of the effectiveness and results of the triennial review on the state’s website. States are also required to submit the results of the review to CMS for input prior to adopting as final. These requirements apply to separate CHIP by cross reference at § 457.1240(d). Effective date: The removal of PCCM entities from EQR requirements, July 9, 2024; transparency and public comment rules, July 9, 2025.

External Quality Review (§§ 438.350, 438.354, 438.364, 457.1240, 457.1250)

External quality review (EQR) is an ongoing requirement for states to contract with an approved external quality review organization (EQRO) to perform an annual review for each contracted managed care entity. External quality review must be conducted for specific mandatory activities including validation of performance measures and improvement projects, compliance with disenrollment and enrollment requirements, and evaluation of network adequacy, among other standards. States may also conduct certain optional EQR activities, including a new provision allowing states to evaluate quality strategies, SDPs, and ILOS that pertain to outcomes, quality, or access to health care services as an EQR activity. The rule applies to CHIP except for the provision relating to SDPs, which are not applicable to CHIP. Effective date: July 9, 2024.

The rule improves transparency by requiring EQR technical reports to include specific data from the mandatory network adequacy validation activity, as well as any outcomes data and results of quantitative assessments, such as the percentage of enrollees who participated in a performance improvement project (PIP) or patient satisfaction based on the outcomes of the PIP. It must include an assessment of health plans’ strengths and weaknesses for quality, timeliness, and access to care, as well as recommendations for improving the quality of health care services and how the state can target goals and objectives in the quality strategy to improve quality and access. Effective date: Beginning July 9, 2024, and annually thereafter, states must post the EQR technical report by April 30 and notify CMS within 14 days of its posting. No later than December 31, 2025, states are required to maintain at least five years of EQR technical reports on their website.

Medicaid Managed Care Quality Rating System (§§ 438.500-535, 457.1240(d))

The Medicaid managed care quality rating system (QRS) is intended to hold states and plans accountable for the quality of care provided to Medicaid and CHIP enrollees; to arm enrollees with useful information about plans available to them; and to provide a tool for states to drive improvements in plan performance and the quality of care provided by their programs. However, it was limited to a single overall rating of each managed care plan, which lacks the level of granularity that individuals need to make an informed choice when selecting a plan that best meets their specific needs, based on their age, gender, location, and health status. The Managed Care Rule advances the QRS as a one-stop-shop where enrollees can access information about Medicaid and CHIP eligibility and managed care; compare plans based on quality and other factors key to plan selection, such as the plan’s drug formulary and provider network; and select a plan that meets their needs. It also requires that states use their beneficiary support systems to assist applicants and enrollees with using the QRS.

As part of its quality assessment and improvement strategy, states must adopt the QRS framework developed by CMS, but they have the option to use the CMS rating methodology or an alternative rating methodology that yields comparable results and is approved by CMS. The QRS must include all measures in the mandatory QRS measure set as described in the QRS technical resource manual, regardless of whether the state implements the model rating methodology or adopts a CMS-approved alternative rating methodology. States must report quality ratings for each mandatory quality measure at the plan level for each managed care program, a significant improvement over the current requirement for a single quality rating for each plan.

At least every other year, CMS will engage the states and other interested parties (state officials, measure experts, health plans, beneficiary advocates, tribal organizations, health plan associations and EQROs) and provide public notice and opportunity to comment on modifications to the mandatory measure set. Mandatory measures must meet at least five of six criteria including if the measure: (1) is meaningful and useful for beneficiaries or their caregivers in choosing a managed care plan; (2) aligns with the mandatory measure set and other CMS quality measurement and rating initiatives; (3) assesses health plan performance in at least one of these specific areas: customer experience, access to services, health outcomes, quality of care, health plan administration, and health equity; (4) presents an opportunity for MCOs to influence their performance on the measure; (5) is feasible for states and plans to report without undue burden; and (6) demonstrates scientific acceptability by producing consistent and credible results.

CMS may make non-substantive changes such as updates to clinical codes or narrowing the denominator or population served as needed. For substantive changes, the rule calls for a public notice and comment period. A measure may be removed if the external measure steward retires or stops maintaining a mandatory measure; [27] there are changes in clinical guidelines associated with the measure; or there is low statistical reliability in the measure. CMS will update guidance to states on mandatory measures in the annual technical resource manual. Effective date: States must implement their managed care quality rating system by December 31, 2028, and thereafter, will have at least two calendar years to implement changes described in the annual technical resource manual. 

QRS Website Display (§§ 438.520, 457.1240(d))

As a second phase of the quality rating system, the rule establishes requirements for a robust, interactive website display, which must comply with accessibility standards and was informed by intensive consultation with prospective users and iterative testing of a QRS website prototype. The display components must include information to help navigate and understand the content of the QRS website, including a statement of the purpose of the QRS, how to use the information to select a plan, how to access the beneficiary support system, and how personal information will be used.

The display must allow beneficiaries to identify MCOs available to them that align with their coverage needs and preferences. This includes identifying all managed care programs and plans for which a user may be eligible based on their age, geographic location, and dually eligible status (if applicable), as well as other demographic data. Additionally, it must include a description of the drug coverage for each managed care plan, including specific formulary information, as well as provider directory information or other provider information specified by CMS. Last, but not least, the display must include quality ratings, as well as any mandatory measures that must be stratified by dual eligibility status, race and ethnicity, and sex.

States will also be required to provide standardized information, specified by CMS, for each managed care plan that allows users to compare plans and programs including the plan name, internet hyperlink to the plan’s website and customer service telephone toll-free hot line. Standardized information will also include premium and cost-sharing; a summary of benefits and differences in benefits among available MCOs including other CMS specifications such as whether prior authorization is required; and other metrics of managed care performance such as the results of secret shopper surveys. Information on quality ratings included in the website display must promote beneficiary understanding and trust in the ratings, including the use of plain language. Additionally, the website must include information or hyperlinks to resources on how and where to apply for Medicaid and how to enroll in a Medicaid or CHIP plan. Effective date: The rule does not establish a firm data for the website display but indicates that it will be required no earlier than two years after the implementation date for the quality rating system (no earlier than December 31, 2030).

Technical Resource Manual (§§ 438.530, 457.1240(d))

Beginning in calendar year 2027, CMS will publish a Medicaid managed care QRS technical resource manual annually. The manual will identify all Medicaid managed care QRS mandatory measures, any measures newly added or removed from the prior year, and the subset of measures that must be displayed and stratified by factors such as race and ethnicity, sex, age, rural/urban status, disability, and language. It must also provide guidance on the methodology used to calculate and issue quality ratings, as well as the measure steward’s technical specifications for mandatory measures. It must also include a discussion of the interested party feedback and recommendations, the rationale for not accepting or implementing specific recommendations, and final modifications and timelines for implementation.

Annual State QRS Report (§§ 438.535, 457.1240(d))

Upon CMS request with no less than 90 days advance notice, and no more frequently than annually, the state must submit a Medicaid managed care QRS report in a form and manner determined by CMS. The report must include a list of mandatory measures identified in the most recent technical resource manual and the managed care program to which the measure applies. If a mandatory measure is not applicable, the state must provide a brief explanation as to why. The report must also include a list of any additional measures the state chooses to include in the QRS. In the report, the state must attest that all displayed ratings for mandatory measures were calculated and issued in compliance with these rules, as well as any deviations from the methodology. It must also include a summary of each alternative QRS rating methodology that has been approved by CMS and the effective date thereof. Effective date: July 9, 2024.

HCBS Quality Measure Set and Reporting (§§ 441.311(c), 441.312, 441.474(c), 441.585(d), 441.745(b)(1)(v))

In 2022, CMS released a set of nationally standardized quality measures for Medicaid-funded HCBS, however, use of the measure set was largely voluntary. [28] The rule sets forth a formal process for measure development and requires states to use and report on the HCBS Quality Measure Set in section 1915(c) waiver programs, and section 1915(i), (j), and (k) authorities. [29]

Beginning no later than December 31, 2026, the Secretary of HHS must identify and update the HCBS Quality Measure Set no more frequently than every other year. As part of the process for measure development, the Secretary of HHS is required to update the HCBS Quality Measures Set through a public process that allows for input from a variety of stakeholders such as states; providers, including direct care workers and groups; consumers; and national organizations and individuals with expertise in HCBS quality measurement. This includes identifying measures to add or remove, which measures are mandatory, potential phase-in periods for complex measures, the subset of measures that must be stratified by race, ethnicity, sex, age, rural/urban status, disability, language or other factors, and other requirements such as those related to technical requirements and procedures and reporting formats. It also includes identifying specific populations for which states must report the measures, including individuals enrolled in managed care or receiving services via FFS.

Under the reporting requirements, states must report every other year on all mandatory measures in the HCBS Quality Measure Set according to the format and schedule prescribed by the Secretary; this includes a potential phase in of mandatory state reporting for certain measures and populations as determined by the Secretary. The rule specifically requires a phased-in approach for measures for which the Secretary has specified that reporting should be stratified. Under the stratification phase-in, the Secretary must require stratification of 25 percent of the applicable measures by July 2028, 50 percent by July 2030, and 100 percent by July 2032. States may also report on the optional measures and some measures may be reported by HHS on behalf of the states. As part of state reporting requirements, states must also establish performance targets for each of the measures and describe the quality improvement strategies that the state will pursue to achieve the performance targets. The rule notes that CMS plans to provide States with technical assistance and subregulatory guidance to support implementation of the HCBS Quality Measure Set. Effective dates: The Secretary must identify and update the HCBS quality Measure Set by December 31, 2026. States must then comply with the HCBS Quality Measure Set reporting requirements by July 9, 2028 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date . Required stratification of applicable measures is phased-in over a number of years under the rule starting with 25 percent in 2028 going up to 100 percent by 2032.

Transparency and Monitoring of Medicaid Managed Care

The Managed Care Rule includes provisions to improve the public availability of information about the performance of MCOs in furnishing services to enrollees and, in doing so, improving the performance of state Medicaid agencies in monitoring the MCOs with which they contract. The timelines for implementation of these transparency requirements are extended, [30] but when fully implemented, these provisions will give enrollees, advocates, and the public better ability to hold MCOs and agencies accountable for the accessibility and quality of care.

Website Navigability (§§ 438.10(c)(3), 457.1207)

Currently, state Medicaid agencies are required to maintain a website that provides specified content for enrollees and the public, either directly or through links to MCO websites. Although this requirement has been in effect since 2017, state compliance remains uneven. As CMS notes in the preamble to the rule, “ There is variation in how ‘user-friendly’ States’ websites are, with some States making navigation on their website fairly easy and providing information and links that are readily available and presenting required information on one page. However, we have not found this to be the case for most States.” [31]

The rule requires that state Medicaid and CHIP agency websites place “clear and easy-to-understand labels” on documents and links and include all content on one webpage, either directly or by link to individual MCO websites. The rule further requires that state agencies verify the accurate function of their websites and the timeliness of the information presented, at least quarterly. Effective date: This requirement for easily navigable, accurate websites will take effect for contract rating periods beginning on or after July 9, 2026 . 

Website Content (§§ 438.207(d)(2), 438.520, 438.602(g), 457.1240(d) and 457.1285)

Under current regulations, state Medicaid agencies are required to post on their websites certain information about their managed care programs.  This information includes the risk contract with MCOs; enrollee handbooks, provider directories, and formularies; the state’s network adequacy standards; documentation that each MCO has adequate capacity to make its services accessible to enrollees; and the annual report by the state’s EQRO assessing the performance of each MCO.

The Managed Care Rule builds upon these transparency requirements by expanding the content required for the agency websites. Among the additional items that state agencies must post are: documentation of the availability of services from each MCO, ( July 9, 2025 ); documentation of compliance with mental health/substance use disorder parity ( July 9, 2026 ); state standards for appointment wait times ( July 9, 2027 ); state directed payment (SDP) evaluation reports ( July 9, 2026 ); and the results of secret shopper surveys ( July 9, 2028 ). (Note each requirement is not applicable until the first rating period beginning on or after the effective dates shown in italics.) These requirements are generally applicable to separate CHIP programs by cross reference at § 457.1285, with some exceptions (e.g., excluding references to SDPs).

As of January 2027 in most states, the documentation of availability of services, above, will be required to include an analysis of the levels of payment by each MCO to its network providers in relation to Medicare payment rates for primary care, OB/GYN, mental health, and substance use disorder services.  If these percentages vary between services for children and services for adults then states must present them separately.

As explained in section V above, the rule also requires that state Medicaid agencies develop a Quality Rating System (QRS) that enables beneficiaries to make an informed choice about which MCO is best for them and their family.  The rule requires the agencies to “prominently display and make accessible to the public” on their improved websites the quality ratings and other information about each MCO. The QRS website display requirement also applies to separate CHIP by cross reference at § 457.1240(d).  The effective date for standing up this QRS website display is no earlier than December 31, 2030 (2 years after the implementation date for the QRS system).

Managed Care Annual Program Report (§438.66(e))

One of the items that state Medicaid agencies are currently required to post on their websites is their Managed Care Program Annual Report (MCPAR).  The purpose of these reports is to “allow CMS…to target efforts to assist states in improving their managed care programs while also ensuring compliance with managed care statutes and regulations, such as ensuring access to care.”  The reports, which are due to CMS within six months of the end of a contract year, include information on the availability and accessibility of services in each MCO, the quality and financial performance of each MCO, and any sanctions imposed.

Although states are required to post these reports on their websites, compliance is uneven. [32] The rule underscores this requirement by specifying that state agencies post their MCPARs within 30 days of submitting them to CMS.  This requirement took effect July 9, 2024 .  The rule also adds to the list of required reporting elements in the MCPAR the results of enrollee experience surveys for each MCO and data on the ILOS, if any, that each MCO provides.  Effective date: This requirement will take effect for contract rating periods beginning on or after July 9, 2027.

Transparency and Monitoring of Home and Community Based Services

As noted in the Access Rule, reports, including those from the Office of Inspector General and Government Accountability Office, have found systemic issues with state HCBS health and safety policies and procedures highlighting serious risks associated with poor quality care and inadequate oversight of HCBS in Medicaid. [33] Appropriate and meaningful health and safety policies and procedures are particularly important for vulnerable populations such as children. Based on such reports and findings as well as stakeholder input, the rule establishes a number of new state incident management and grievance systems requirements.

HCBS Incident Management System (§§ 441.302(a)(6), 441.311(b), 441.464(e), 441.570(e), 441.745(a)(1)(v) and (b)(1)(i))

Under the Access Rule, states must provide an assurance that they operate and maintain an incident management system that identifies, reports, triages, investigates, resolves, tracks, and trends critical incidents for individuals receiving HCBS services under section 1915(c) waiver programs and 1915(i), (j), and (k) HCBS programs, including services delivered via managed care. [34] The rule also establishes a standard definition of what constitutes a “critical incident” to address the lack of a standardized federal definition for the type of events or instances that states should consider a critical incident and must be reported and considered for investigation. States must also require providers to report to the state (within state-established timeframes and procedures) any critical incidents that occur during the delivery of services specified in the individual’s person-centered plan, or result due to the failure to deliver such services.

In implementing the systems, states must enable electronic data collection, tracking, and trending and must use data including claims data and Medicaid Fraud and Control Unit data to identify critical incidents that are unreported by providers or occur as a result of the failure to deliver services and share information on the status and resolution of investigations with other entities in the state responsible for investigation of critical incidents. States must also separately investigate critical incidents if the investigative agency fails to report the resolution of an investigation within state-specified timeframes and meet reporting requirements related to their incident management system. As part of this reporting, the rule codified a 90 percent minimum performance standard for state demonstration of a number of critical incident requirements including that an investigation was initiated for no less than 90 percent of critical incidents.

With the rule, states must report annually to CMS on certain critical incidents, such as those for which an investigation was initiated, and on the results of an incident management system assessment every two years (unless CMS determines the system meets the requirements at which point the assessment must be done every five years). Effective dates: States must implement the incident management system requirements by July 9, 2027 in FFS, and in the case of managed care, for contract rating periods beginning on or after that date , however, states have until July 9, 2029 (or contract rating periods beginning on or after that date in managed care) to enable electronic critical incident data collection, tracking, and trending.

HCBS Grievance Systems (§§ 441.301(c)(7), 441.464(d)(5), 441.555(e), 441.745(a)(1)(iii))

Among other requirements, the ACA requires development and monitoring of a HCBS complaint system. [35] While existing regulations include fair hearing rights that apply across Medicaid, including for individuals receiving HCBS, current regulations do not provide a venue to raise concerns about issues that are not covered by the fair hearing process that individuals receiving HCBS services in the FFS delivery system may experience, such as failure of a provider to comply with the HCBS settings requirements. Accordingly, the rule establishes state grievance procedures for individuals receiving services under 1915(c), (i), (j), and K authorities through a FFS delivery system. [36]

Under the rule, states must establish procedures for individuals to file a grievance related to the state or provider’s compliance with the person-centered planning and service plan requirements and HCBS settings requirements. Grievances may be filed orally or in writing at any time and by individuals themselves or their authorized representatives – who are also allowed to represent them throughout the process. States must provide reasonable assistance to individuals in filing grievances, including help for individuals with disabilities or limited English proficiency. The rule includes a number of requirements related to state handling, recordkeeping, and accessibility related to the grievance process including that decisions on grievances must be made by individuals who were not involved in the initial decision and who have appropriate expertise. States must keep detailed records of all grievances, including the reason for the grievance, dates of review, and the resolution, and ensure no punitive or retaliatory actions are taken against individuals who file grievances.

Under the rule, grievances must be resolved as quickly as the individual’s health condition requires, but no later than 90 calendar days from when the grievance is received with notice of the resolution provided to them in an accessible format. The state is permitted to extend the timeline by up to 14 days if the individual requests the extension, or the state documents that there is need for additional information and how the delay is in the individuals’ best interest. Effective date: States are required to comply with the grievance system requirements by July 9, 2026.

Technical Changes for State HCBS Reporting Requirements (§§ 441.474(c), 441.580(i), 441.745(a)(1)(vii))

In accordance with ACA requirements for states to achieve a more consistent administration of policies and procedures across HCBS programs and to ensure appropriate state reporting of HCBS requirements included in the rule, the rule modifies various regulatory sections for HCBS authorities to clarify that references to section 1915(c) are instead references to section 1915(j), (k), and (i), where applicable. Effective dates: July 9, 2024.

HCBS Website Transparency (§§ 441.313, 441.486, 441.595, 441.750)

To ensure that information about the accessibility and quality of HCBS services is available to Medicaid applicants and beneficiaries, the Access Rule requires state Medicaid agencies to operate a consumer-friendly website that contains the results of the reports that states are required to submit to CMS.  More specifically, website must present the results of state reporting on (1) the state’s incident management system; (2) critical incidents; (3) reassessments for functional need; (4) results from the HCBS Quality Measures Set identified by CMS; (5) waiver waiting lists; (6) access to homemaker, home health aide, personal care, and habilitation services; and (7) adequacy of payment for those services.  In states that establish a separate payment adequacy standard for small employers or exempt providers from any requirement in cases of hardship, the website must also present the percentages of providers qualifying for one or both exemptions.

State agencies must verify the accurate function of the website and the timeliness of the information at least quarterly.  These website requirements apply to states providing HCBS services under sections 1915(i), 1915(j), and 1915(k) as well as under 1915(c). The rule also requires that CMS report on its website the results submitted by states; this will ensure that applicants and beneficiaries have a source of information if their state Medicaid agency does not post the required information.   Effective date: These website transparency requirements are effective for state agencies July 9, 2027, except that if a state includes HCBS services in its contracts with MCOs, for contract rating periods beginning on or after that date. The website transparency requirement for CMS is effective July 9, 2024.

The authors would like to thank Joan Alker, Catherine Hope, and Madeline McBride. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based at the McCourt School of Public Policy. Support for this report was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

Editor’s Note: An “Implementation Timeline” is available in the PDF version of this report.

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[1] “March 2024 Medicaid & CHIP Enrollment Data Highlights,” Centers for Medicare and Medicaid Services, available at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html .

[2] R. Rudowitz et al., “10 Things to Know About Medicaid” (San Francisco: KFF, June 2023), available at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/ .

[3] “Medicaid Program; Ensuring Access to Medicaid Services,” Federal Register 89: 40542-40874 (May 10, 2024).

[4] “Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality,” Federal Register 89: 41002-41285 (May 10, 2024).

[5] There are 10 states without Managed Care: AL, AK, CT, ID, ME, MT, OK, SD, VT, WY. “Total Medicaid MCO Enrollment,” KFF, available at https://www.kff.org/other/state-indicator/total-medicaid-mco-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D .

[6] “The Patient Protection and Affordable Care Act,” Public Law 111-148, 124 Stat 119 § 2402 (2010), available at https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf .

[7] M. Ralls, “Using Medicaid Payment Strategies to Support Family Caregivers and Direct Care Workers,” (Hamilton, New Jersey: Center for Health Care Strategies, February 2022), available at https://www.chcs.org/using-medicaid-payment-strategies-to-support-family-caregivers-and-direct-care-workers/ .

[8] The rule notes that while the advising and consulting requirements are limited to these services, states have the discretion to have the IPAG advise on additional services. In addition, states also retain the flexibility to have the group advise on provider payment rates in managed care delivery systems.

[9] Agency for Healthcare Research and Quality, “What is Patient Experience?” (Rockville, Maryland: Agency for Healthcare Research and Quality, July 2024), available at https://www.ahrq.gov/cahps/about-cahps/patient-experience/index.html .

[10] Currently, 34 states operate a separate CHIP program, either exclusively or in combination with enrolling CHIP children in Medicaid. Of these separate CHIP program states, 27 use MCOs to deliver covered services to CHIP children (the other seven use the FFS delivery system). A. Schneider et al., “An Introduction to Managed Care in CHIP” (Washington: Center for Children and Families, March 24, 2023), available at https://ccf.georgetown.edu/2023/03/24/an-introduction-to-managed-care-in-chip/ .

[11] 89 Fed. Reg. 40567 (May 10, 2024).

[12] Supra note 6.

[13] E. Park et al., “Consolidated Appropriations Act, 20233:  Medicaid and CHIP Provisions Explained” (Washington: Center for Children and Families, January 5, 2023), available at https://ccf.georgetown.edu/2023/01/05/consolidated-appropriations-act-2023-medicaid-and-chip-provisions-explained/

[14] Note the SHO also provides guidance on provider directory requirements for FFS delivery systems.  D. Tsai, “SHO #24-003, RE: Consolidated Appropriations Act, 2023 Amendments to Provider Directory Requirements” (Baltimore: Centers for Medicare & Medicaid Services, July 16, 2024), available at https://www.medicaid.gov/federal-policy-guidance/downloads/sho24003.pdf .

[15] S. Corlette et al., “Access to Services in Medicaid and the Marketplaces:  Comparing Network Adequacy Rules” (Washington: Center on Health Insurance Reforms and Center for Children and Families, March 1, 2022), available at https://www.rwjf.org/en/insights/our-research/2022/03/assessing-federal-and-state-network-adequacy-standards-for-medicaid-and-the-marketplace.html .

[16] M. Yiu and D. Machledt, “Secret Shopper Surveys:  A Powerful Too. For Directly Testing Medicaid Managed Care Enrollees’ Access to Care” (Washington: National Health Law Program, April 24, 2024), available at:   https://healthlaw.org/secret-shopper-surveys-a-powerful-tool-for-directly-testing-medicaid-managed-care-enrollees-access-to-care/ .

[17] A. Burns, M. Mohamed, and M. O’Mally Watts, “A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2023” (San Francisco: KFF, November 29, 2023), available at https://www.kff.org/medicaid/issue-brief/a-look-at-waiting-lists-for-medicaid-home-and-community-based-services-from-2016-to-2023/ .

[18] 89 Fed. Reg. 40643 (May 10, 2024).

[19] 89 Fed. Reg. 40692 (May 10, 2024).

[20] CMS, “Ensuring Access to Medicaid Services – A Guide for States to the Fee-For-Service Provisions of the Final Rule” (Baltimore: Centers for Medicare & Medicaid Services, July 2024), available at https://www.medicaid.gov/medicaid/access-care/downloads/ffs-prov-final-rule-guidance.pdf .

[22] MACPAC, “Directed Payments in Medicaid Managed Care” (Washington: Medicaid and CHIP Payment and Access Commission, June 2023), available at https://www.macpac.gov/wp-content/uploads/2023/06/Directed-Payments-in-Medicaid-Managed-Care.pdf .

[23] 89 Fed. Reg. 41073 (May 10, 2024).

[24] D. Tsai, “Exercise of Enforcement Discretion until Calendar Year 2028 for Existing Health Care-Related Tax Programs with Hold Harmless Arrangements Involving the Redistribution of Medicaid Payments” (Baltimore: Centers for Medicare & Medicaid Services, April 22, 2024), available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib042224.pdf .

[25] 42 C.F.R. 438.2 (2024).

[26] “Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality,” Federal Register 88: 28092-28252 (May 3, 2023), available at https://www.federalregister.gov/documents/2023/05/03/2023-08961/medicaid-program-medicaid-and-childrens-health-insurance-program-chip-managed-care-access-finance .

[27] A measure steward is an individual or organization that owns a measure and is responsible for maintaining the measure. Measure stewards may also be measure developers. Measure stewards are also the ongoing point of contact for people interested in a given measure e.g., medical specialty society or federal health agency. “Measure steward,” Electronic Clinical Quality Improvement (eCQI) Resource Center, available at https://ecqi.healthit.gov/glossary/measure-steward .

[28] D. Tsai, “SMD# 22-003, RE: Home and Community-Based Services Quality Measure Set,” (Baltimore: Centers for Medicare & Medicaid Services, July 21, 2022), available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd22003.pdf .

[29] The rule does not apply the HCBS reporting requirements to 1905(a) HCBS services.

[30] A. Schneider, “A Closer Look at Transparency in the Medicaid Managed Care Rule” (Washington: Center for Children and Families, May 17, 2024), Table 2, available at https://ccf.georgetown.edu/2024/05/17/a-closer-look-at-transparency-in-the-medicaid-managed-care-rule/ .

[31] 89 Fed. Reg. 41038 (May 10, 2024).

[32] A. Schneider, “Transparency in Medicaid Managed Care:  The MCPAR Saga Continues” (Washington: Center for Children and Families, June 24, 2024), available at https://ccf.georgetown.edu/2024/06/24/transparency-in-medicaid-managed-care-the-mcpar-saga-continues/ .

[33] HHS OIG, HHS ACL, and HHS OCR, “Joint Report: Ensuring Beneficiary Health and Safety in Group Homes Through State Implementation of Comprehensive Compliance Oversight” (Washington: U.S. Department of Health and Human Services Office of Inspector General, Administration for Community Living, and Office for Civil Rights, January 2018), available at https://oig.hhs.gov/reports-and-publications/featured-topics/group-homes/group-homes-joint-report.pdf ; HHS OIG, “State Compliance with Requirements for Reporting and Monitoring Critical Incidents” (Washington: U.S. Department of Health and Human Services Office of Inspector General), available at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000264.asp ; and GAO, “Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare is Needed” (Washington: U.S. Government Accountability Office, January 5, 2018), available at https://www.gao.gov/products/gao-18-179 .

[34] The rule does not mandate inclusion of section 1905(a) services in state requirements for incident management systems, but acknowledges that many individuals, particularly those receiving mental health services, are served by section 1905(a) services, and encourages states to consider development of critical incident processes to address protections for individuals from harm or events that place a beneficiary at risk of harm.

[35] Supra note 6.

[36] This requirement to establish a grievance system does not apply to managed care delivery systems with the rule noting that the requirements are similar to those for managed care grievance requirements. The rule also does not mandate inclusion of section 1905(a) services in state grievance systems, but acknowledges that many individuals, particularly those receiving mental health services, are served by section 1905(a) services, and encourages states to consider development of a grievance process to address concerns.

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• Life Insurance
• Best Long Term Care Insurance Companies

Best Long-Term Care Insurance Companies Of 2024

Fact Checked

Updated: Feb 15, 2024, 11:35am

Many adults need long-term care as they get older. Someone turning the age of 65 today has nearly a 70% chance of needing long-term care assistance in their lifetime, according to the Administration for Community Living.

We analyzed coverage prices to find the best long-term care insurance policies.

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Best Long-Term Care Insurance of 2024

Bankers life, national guardian, thrivent financial, summary: comparing the best long-term care insurance companies, what is long-term care insurance, how does long-term care insurance work, what is covered by ltc insurance, what is not covered by ltc insurance, how much does long-term care insurance cost, factors that affect the cost of ltc insurance, can anyone get ltc insurance, who needs long-term care insurance, alternatives to long-term care insurance, state long-term care partnership programs, methodology, long-term care insurance frequently asked questions (faqs), compare long term care insurance plans from top insurers, ltc consumer.

Coverage Amount

Up to $500,000

Eligible Ages

• Bankers Life – Best for Maximum Issue Age
• National Guardian – Best for Maximum Benefits Period
• Thrivent Financial – Best for Minimum Issue Age

Best for Maximum Issue Age

Policy name

SimpleChoice Standard

Maximum issue age

Maximum benefits period

Bankers Life’s SimpleChoice Standard policy has a generous maximum issue age. There’s a no elimination period option, which means you can take advantage of long-term care benefits immediately.

• High maximum issue age of 84.
• Lowest average costs in our analysis.
• Provides an option for an elimination period of 0 days.
• Offers four levels of benefit increases (2%, 3%, 4% and 5%), which helps you offset inflation.
• Maximum benefits period is two years, which may not be enough depending on how long you need long-term care.
• Informal family care isn’t reimbursable, unlike some LTC policies from competitors.

Best for Maximum Benefits Period

EssentialLTC

National Guardian’s EssentialLTC policy offers a lifetime maximum benefits option, which is unlike competitors that may put a cap on LTC benefits, such as two or five years.

• Offers an option for lifetime maximum benefits for long-term care insurance.
• Competitive pricing for long-term care coverage.
• Minimum elimination period of 30 days is better than some competitors.
• Issue age for buying the policy is only between 40 and 79 years old. Some competitors will sell LTC insurance to buyers of older ages.
• Doesn’t reimburse for informal family care.

Best for Minimum Issue Age

Thrivent Long-Term Care Insurance

Thrivent Financial allows people as young as 18 years old to buy long-term care insurance, so Thrivent might make sense for people in their 30s who may have trouble finding LTC insurance elsewhere.

• Maximum benefits period of 8 years is better than some competitors.
• Minimum elimination period of 30 days is good, though not as good as Bankers Life’s no elimination period option.
• Issue ages of 18 to 79 allows younger people to buy long-term care coverage.
• Homemaker services are reimbursed at the same level as custodial care.
• Offers combination life insurance policies, which combine life coverage with long-term care insurance components.
• Thrivent’s average long-term care insurance premiums were one of the highest in our analysis.
• Informal family care isn’t reimbursable.

Long-term care (LTC) insurance is a policy that covers expenses related to long-term care. Most LTC insurance policies cover services like adult day care, hospice, nursing home stays and help with activities of daily living (ADLs), like dressing and eating.

The average cost of a private room in a nursing home is $7,698 a month and a home health aide costs more than $20 an hour on average, according to the Association for Community Living (ACL).

Having an LTC insurance policy can dramatically reduce what you have to pay for long-term care.

Stand-alone long-term care insurance isn’t widely available anymore. Only about a dozen private insurance providers offered long-term care insurance policies in 2020 and that number has dwindled even more over the past two years. The American Association for Long Term Care Insurance (AALTCI) says only six companies currently sell standard long-term care insurance policies:

• ​​Bankers Life
• Mutual of Omaha
• National Guardian Life
• New York Life
• Northwestern Mutual

Types of Long-Term Care Insurance

There are multiple ways to get long-term care insurance.

• Stand-alone long-term care insurance policy: This type of coverage provides only long-term care insurance. You can generally add an inflation rider that increases benefits over the years, such as by 3% or 5%. Putting that rider on a LTC policy will likely increase your cost since it bumps up the policy’s value.
• Linked benefit life insurance: A combination life insurance policy, also called a hybrid life insurance policy, is life coverage combined with long-term care insurance. Using the policy for LTC services reduces the death benefit. If you don’t need LTC, your survivors get the full death benefit when you die.
• Life insurance policy with LTC rider: You can often buy life insurance coverage with a long-term care rider. Life insurance riders don’t typically offer as much coverage as a hybrid life insurance/LTC policy, but is likely more affordable than a hybrid policy.
• Critical illness insurance: Critical illness insurance can be used to to pay for long-term care if you’re diagnosed with a specific illness that’s listed in the policy, such as cancer or a heart attack. These types of policies pay a lump sum, such as $25,000 or $30,000. Critical illness policies don’t continue to pay over a benefits period, like LTC insurance does, so they don’t offer as much coverage as other options.

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LTC insurance benefits can only be used when you experience a benefit trigger. These triggers will be listed in the policy. LTC insurance policies have benefit triggers such as:

• Needing assistance with at least two ADLs for 90 days (personal hygiene or grooming, dressing toileting, eating and transferring, which means the ability to move from a bed to chair or wheelchair).
• Experiencing a cognitive impairment.
• Recommendation from a medical doctor.

Before LTC benefits begin, you might have a waiting period, called an elimination period. The waiting period might be anywhere from 20 to 100 days before the policy starts paying for long-term care. Once the waiting period ends, your insurance company covers costs.

The length of time LTC benefits are in effect varies by policy. Some long-term care insurance policies cover only qualifying expenses for a few years or until you reach a maximum benefit limit. Other policies provide coverage for your lifetime.

How Long-term Care Insurance Benefits Are Paid

Long-term care insurance payments work in one of three ways:

• Expense-incurred: Pays the lesser of either the expense or policy’s value amount.
• Indemnity method: Pays solely based on a set dollar amount.
• Disability method: Pays the full daily benefit amount if you meet the benefit eligibility criteria regardless of whether you’re receiving long-term care.

Maximum LTC Benefits

Long-term care insurance policies generally have a maximum benefit limit, which is the most the policy will pay out if you need services. Policies may limit coverage for a number of years, while others have a dollar ceiling. Long-term care policies often pay benefits by day, week or month, though some policies may pay one time for single events.

Long-term care policies let you choose a benefit amount for nursing care, but they may also pay for home care coverage. Home care coverage may pay at the same level as nursing care or may be capped at a percentage of nursing care coverage, such as 50%.

Inflation Protection

Inflation can play a role in how much your policy pays. If the benefits don’t increase over time from when you buy the policy, it may not offer enough protection decades later when you need long-term care. That’s why long-term care insurance policies often offer inflation protection.

Inflation protection keeps long-term care payments at pace with inflation. Automatic inflation protection increases benefit amounts each year without a higher cost to policyholders. This feature may increase by a fixed amount each year, such as 3%, for a limited time or for the life of the policy.

Another option for inflation protection is to increase long-term care benefits every few years. This special offer option may require that you prove your health hasn’t deteriorated. Going this route will likely increase your long-term care insurance costs. The specific increase depends on your age and how much you increase benefits.

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Long-term care insurance covers many expenses commonly associated with long-term care, whether you need assistance at home or in a facility, such as:

• Nursing home care
• Hospice care
• Home health aides
• Respite care
• Adult daycare centers
• Physical therapy
• Occupational therapy
• Speech therapy

It’s important to check the policy for exclusions before you buy it. For example, some long-term care insurance policies may only pay for care in a state-licensed facility, while others will only cover care in specific state-licensed facilities. Some policies may exclude coverage for care received in a facility considered a rest home or personal care home.

Long-term care insurance can’t be used in some situations, such as:

• Mental health or nervous disorders (besides dementia)
• Alcohol or drug addiction
• War-related illnesses or injuries
• Self-inflicted injuries
• Treatment in a government facility
• Treatment that has already been paid for by the government
• Long-term care treatment outside the U.S. except some policies that cover care in Canada and the United Kingdom.
• The average LTC insurance cost is $1,900 a year for a 60-year-old female.
• The average cost is $1,175 a year for a 60-year-old male.
• The average cost for a 60-year-old couple is $2,600 annually, combined.

Those averages are for long-term care insurance policies with $165,000 level benefits, according to the American Association for Long Term Care Insurance (AALTCI).

You can also add a policy provision that increases the benefits by a percentage, such as 3% each year, to offset inflation.

Average Annual Costs for Long-Term Care Insurance

Source: American Association of Long Term Care Insurance.

Although long-term care insurance can be expensive, it may be worth the cost when considering the prices of common long-term care services.

Average Long-Term Care Costs

How much does long-term care cost with insurance? That depends on the specific policy. Here’s an example.

Imagine you have an LTC insurance policy that provides $5,000 per month for nursing home care and your nursing home expenses are $7,800 per month. In this case, your LTC insurance policy would cover the first $5,000, leaving you to pay $2,800 out-of-pocket.

LTC insurance premiums are unique to each individual. When you apply, the insurance company reviews multiple factors to determine how much you should pay. If you’re shopping for the best long-term care insurance, these factors will typically be used for pricing.

Age and Health

Your age and health has a big impact when you purchase LTC insurance. You may not qualify for LTC insurance if you have pre-existing health conditions.

Older buyers pay more for coverage. But there’s a catch—buying a policy at a younger age, such as when you’re in your 50s, means you will likely pay premiums for a longer time until you need care.

There’s also a chance you’ll get denied coverage if you try to get long-term care in your 70s. AALTCI estimates that 47.2% of LTC applicants between the ages of 70 and 74 were denied coverage in 2021.

Percentage of Long-Term Care Insurance Applicants Denied by Age

Women tend to pay higher rates for long-term care insurance because women statistically live longer than men, and therefore may need LTC coverage for a longer period.

Women also tend to experience more chronic health problems than men. Insurance companies price LTC policies higher for women to prepare for the increased likelihood of a benefit trigger during their lifetime.

Individual or Joint LTC Policy

If you’re married and apply for a joint long-term care insurance policy, the premium is usually cheaper than the cost of separate polices for two individuals. The AALTCI estimates that the average cost of a joint LTC insurance policy for a healthy 55-year-old couple is $2,080 per year for benefits of $165,000.

By comparison, the average cost for an individual male is $950 per year and $1,500 per year for females of the same age. A couple buying two individual policies can expect to spend more than $2,450 a year, so going with a joint policy can save money.

Type of Coverage

The cost of long-term care coverage also depends on the specific policy and coverage. This may include a policy’s:

• Pre-set daily limit.
• Maximum benefits, such as lifetime or for a limited time, such as up to two years.
• Elimination period, which is usually between 30 and 90 days.
• Riders you add like inflation protection, which increases long-term care benefits each year based on inflation.

Insurance Company

Insurance companies use different rating systems to calculate premiums. To find the best LTC insurance cost, it’s a good idea to get quotes from a few different long-term care insurance companies.

The AALTCI noted in its 2023 Long-Term Care Insurance Price Index report that prices for the same level of coverage vary significantly. “In some cases, one insurer literally charges more than twice the cost of another for virtually identical coverage,” Jesse Slome, AALTCI director, said in a statement. “I am not sure what accounts for such a significant difference but it reinforces our belief that consumers should do comparison shopping before making a decision.”

Increases in Cost of Care

Long-term care insurance premiums aren’t always fixed, so your rate can increase in the future. These rate increases are often tied to the rising cost of long-term care expenses over time. This can make it hard to budget for the future.

Not everyone can buy LTC insurance. You may not be able to find an LTC insurance policy if:

• You’re currently receiving long-term care services.
• You are in poor health.
• You have pre-existing conditions.
• You are over age 80.

When you apply for long-term care insurance, you need to answer health-related questions to determine your eligibility. You may still qualify for LTC insurance with minor medical conditions, but you will probably pay a higher premium.

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If you don’t think you’ll be able to afford long-term care when you’re older, LTC insurance may be a good investment. Long-term care expenses can add up quickly and deplete your savings, especially if you need permanent care in a nursing home or assisted living facility.

You might also consider long-term care insurance if you don’t want to burden your family with long-term care costs as you age. If your children or surviving loved ones can’t afford to pay for your long-term care, LTC coverage can provide financial peace of mind as you age.

There are several alternatives to LTC insurance. Here are a few ways you can pay for long-term care without purchasing insurance.

Annuity with a Long-term Care Rider

Some annuity contracts offer the option to add a long-term care rider, which provides coverage for qualifying long-term care expenses. An annuity with an LTC rider can be a good option if you want to supplement your income during retirement but don’t want to use your savings to pay for long-term care expenses.

Continuing Care Retirement Community

Continuing care retirement communities allow people to live independently as they age while providing on-site medical care when their medical needs advance. Depending on the community, some residents must purchase long-term care insurance to pay for their future medical care while living in the community.

Personal Savings

Rather than investing in an annuity or an insurance policy, some people prefer to pay for their long-term care expenses entirely out-of-pocket. Although long-term care can be expensive, paying insurance premiums for decades before the benefits are needed can also be a major expense.

If you choose to rely on savings for LTC expenses, make sure to have a solid financial plan going into retirement.

Veterans Affairs Health Care

If you served in the military and are enrolled in VA health care, you can access long-term care through the VA . Many of the services covered by the VA are the same ones covered by long-term care insurance, like nursing home stays, pain management, help with ADLs, adult daycare programs and physical therapy.

Medicare doesn’t automatically cover long-term care, but some forms of assistance are covered if you meet the requirements. For example, Medicare Part A may cover short-term skilled nursing care based on a qualifying hospital stay. However, don’t rely on Medicare for long-term care needs due to the limited circumstances it covers.

If you qualify for Medicaid , you can get access to long-term care benefits, but you must meet the income requirement. This often means spending down most of your assets before Medicaid will take over the payments. Medicaid usually pays for nursing homes and some home health and community health services.

Some states have a partnership with long-term care insurance companies. If you live in one of these states, buying a “partnership policy” prevents you from having to spend down your assets to qualify for Medicaid once you cannot pay for long-term care on your own.

For example, imagine you’re using your long-term care insurance to pay for a nursing home and the insurance company has already paid $70,000 in benefits. Under a state partnership program, you could keep that $70,000 in savings (or investments) and still qualify for Medicaid if your income allows. This is called reciprocity.

To find the best long-term care insurance companies, we evaluated stand-alone LTC policies. Our evaluation was based on:

Premiums for a 60-year-old female and 60-year-old couple (50% of score): We used long-term care insurance rates for a policy without annual benefit increases for the most common rating class with $100 per day benefits or the weekly/monthly equivalent and a 90-day elimination period.

Lowest elimination period (20% of score): We compared each policy’s lowest elimination period, which is the time before you can use long-term care insurance benefits.

Maximum benefits period (20% of score): We looked at each policy’s maximum benefits period, which is how long you’re able to use long-term care insurance benefits.

Maximum issue age (10% of score): We evaluated each policy’s maximum issue age for buying the policy.

When is the best time to buy LTC?

Consider purchasing long-term care insurance in your 50s. As you age, your risk of not qualifying for LTC insurance increases.

More than 47% of LTC insurance applications were denied for people between age 70 and 74 in 2021. Only about 20% of people between age 50 to 59 were denied.

Is long-term care insurance worth it?

Long-term care insurance can be a wise decision, but it depends on your financial situation. If you’re concerned about paying for future long-term care expenses, long-term care insurance can be a good solution.

On the other hand, long-term care insurance is generally very expensive. When you consider how much you would spend in premiums, you might feel more comfortable saving or investing that money to use for long-term care when the time comes.

Can you use an annuity to pay for long-term care?

If you have an annuity, you can use the proceeds to pay for long-term care. The income from an annuity can be used for any purpose, including costs associated with long-term care and other medical expenses.

You can also consider adding a long-term care rider to an annuity contract if the insurance company offers it. A long-term care rider provides coverage for qualifying long-term care expenses without having to spend the annuity payments on your medical care.

Is long-term care insurance tax deductible?

Depending on the type of long-term care insurance policy, you can deduct the premiums on your taxes as a qualifying medical expense. Not all LTC insurance policies have this feature and there’s a limit to the amount you can deduct based on your age. As you get older, the amount you can deduct increases.

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Elizabeth Rivelli has nearly five years of experience covering insurance for finance publications. She has expertise in various insurance lines, including car insurance, health insurance, travel insurance, life insurance and others. In her writing, she aims to make insurance more approachable and understandable for people in all stages of life. Elizabeth also writes for several insurance company blogs.

The independent source for health policy research, polling, and news.

Key Facts on Health Coverage of Immigrants

Published: Sep 17, 2023

Note: This content was updated on June 26, 2024 to include updated information about state coverage for immigrants.

As of 2022, there were 45.5 million immigrants residing in the U.S., including 21.2 million noncitizen immigrants and 24.2 million naturalized citizens, who each accounted for about 7% of the total population. 1 Noncitizens include lawfully present and undocumented immigrants. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. One in four children has an immigrant parent, including over one in ten (12%) who are citizen children with at least one noncitizen parent. 2 This fact sheet provides an overview of health coverage for immigrants based on data from The 2023 KFF/LA Times Survey of Immigrants , the largest nationally representative survey focused on immigrants.

As of 2023, half (50%) of likely undocumented immigrant adults and one in five (18%) lawfully present immigrant adults report being uninsured compared to less than one in ten naturalized citizen (6%) and U.S.-born citizen (8%) adults . 3 Noncitizen immigrants are more likely to be uninsured than citizens because they have more limited access to private coverage due to working in jobs that are less likely to provide health benefits and they face eligibility restrictions for federally funded coverage options, including Medicaid, the Children’s Health Insurance Program (CHIP), Affordable Care Act (ACA) Marketplace coverage, and Medicare. Those who are eligible for coverage also face a range of enrollment barriers including fear, confusion about eligibility rules, and language and literacy challenges. Reflecting their higher uninsured rate, noncitizen immigrants are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Immigrants have lower health care expenditures than their U.S.-born counterparts given their more limited access and use.

Some states have expanded access to health coverage for immigrants. At the federal level, legislation has been proposed that would expand eligibility for health coverage for immigrants, though it faces no clear path to passage in Congress. At the state level, there has been continued take up of state options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant people, and a small but growing number of states have expanded fully state-funded coverage to certain groups of low-income people regardless of immigration status. However, many immigrants, particularly those who are undocumented, remain ineligible for coverage options.

Many immigrants remain fearful of accessing assistance programs, including health coverage. The Biden Administration reversed prior Trump Administration changes to public charge rules , which may help reduce fears among immigrant families about participating in non-cash assistance programs, including Medicaid and CHIP. It also increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty about how use of non-cash assistance programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears.

Overview of Immigrants

Based on federal survey data, as of 2022, there were 45.5 million immigrants residing in the U.S., including 21.2 million noncitizens and 24.2 million naturalized citizens, who each accounted for about 7% of the total population (Figure 1). 4 About six in ten noncitizens were lawfully present immigrants, such as lawful permanent residents (green card holders) and those with a valid work or student visa, while the remaining four in ten were undocumented immigrants, who may include individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired. 5 Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. A total of 19 million or one in four children living in the U.S. had an immigrant parent as of 2022, and the majority of these children were citizens (Figure 1). 6 About 8.6 million or 12% were citizen children with at least one noncitizen parent.

Uninsured Rates by Immigration Status

The 2023 KFF/LA Times Survey of Immigrants , the largest nationally representative survey focused on immigrants, provides data on health coverage of immigrant adults and experiences accessing health care, including by immigration status.

Although the majority of uninsured people are citizens, noncitizen immigrants, particularly likely undocumented immigrants, are significantly more likely to report being uninsured than citizens. As of 2023, half (50%) of likely undocumented immigrants and one in five (18%) lawfully present immigrants say they are uninsured compared to 6% of naturalized citizens and 8% of U.S.-born citizens (Figure 2) . 7

Reflecting their higher uninsured rates, noncitizen immigrants, especially those who are likely undocumented, are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Research shows that having insurance makes a difference in whether and when people access needed care. Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat . Overall, likely undocumented immigrants are more likely than lawfully present immigrants and naturalized citizens to report not having a usual source of care other than an emergency room, not having a doctor’s visit in the past 12 months, and skipping or postponing care in the past 12 months (Figure 3). 8 Lawfully present immigrants also are more likely than naturalized citizens to say they have not had a doctor’s visit in the past 12 months.

Research also shows that immigrants have lower health care expenditures than their U.S.-born counterparts as a result of lower health care access and use, although their out-of-pocket payments tend to be higher due to higher uninsured rates. Recent research further finds that, because immigrants, especially undocumented immigrants, have lower health care use despite contributing billions of dollars in insurance premiums and taxes, they help subsidize the U.S. health care system and offset the costs of care incurred by U.S.-born citizens.

Access to Health Coverage Among Immigrants

Private coverage.

Despite high rates of employment, noncitizen immigrants have limited access to employer-sponsored coverage. Although most noncitizen immigrant adults say they are employed, they are significantly more likely than citizens to report being lower income (household income less than $40,000) (Figure 4). 9 This pattern reflects disproportionate employment of noncitizen immigrants in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Given their lower incomes, noncitizen immigrants also face challenges affording employer-sponsored coverage when it is available or through the individual market.

Federally Funded Coverage

Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to certain eligibility restrictions. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants with qualified status, such as refugees and asylees, as well as citizens of Compact of Free Association ( COFA ) communities,  do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country (Appendix A). For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of March 2024, 37 states plus D.C. have taken up this option for children and 30 states plus D.C. have elected the option for pregnant individuals.

In December 2020, Congress restored Medicaid eligibility for citizens of COFA communities and in  March 2024 , eligibility was restored for additional federally funded programs including CHIP . The U.S. government has COFA agreements with the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Certain citizens of these nations can lawfully work, study, and reside in the U.S., but they had been excluded from federally funded Medicaid since 1996, under the Personal Responsibility and Work Opportunity Reconciliation Act. As part of a COVID-relief package, Congress restored Medicaid eligibility for COFA citizens who meet other eligibility requirements for the program effective December 27, 2020. On March 9, 2024, Congress further extended eligibility for  COFA  citizens to newly include other federally funded programs such as CHIP, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families (TANF), among others.

A total of 22 states have also extended coverage to pregnant people regardless of immigration status through the CHIP  From-Conception-to-End-of-Pregnancy  (FCEP) option .  Colorado  plans to implement this coverage by January 2025. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage regardless of immigration status either through a CHIP state plan amendment or using state-only funding. Additionally, ten states (California, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to individuals regardless of immigration status to align with the  Medicaid extension  established by the American Rescue Plan Act, and Maryland  extends coverage  for four months postpartum through its health services initiative.

Lawfully present immigrants can purchase coverage through the ACA Marketplaces and, like citizens, may receive tax credits to help pay for premiums and cost sharing that vary on a sliding scale based on income. Generally, these tax credits are available to people with incomes starting from 100% of the federal poverty level (FPL) who are not eligible for other affordable coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive tax credits if they are ineligible for Medicaid based on immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five-year waiting period or do not have a “qualified” status.

Lawfully present immigrants also can qualify for Medicare subject to certain restrictions. Specifically, they must have sufficient work history to qualify for premium-free Medicare Part A. If they do not have sufficient work history, they may qualify if they are lawful permanent residents and have resided in the U.S. for five years immediately prior to enrolling in Medicare, although they must pay premiums to enroll in Part A.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare or to purchase coverage through the ACA Marketplaces. Previously, individuals with Deferred Action for Childhood Arrivals (DACA) status were not considered lawfully present for purposes of health coverage eligibility and remained ineligible for these coverage options despite having a deferred action status, which otherwise qualified for Marketplace coverage. On May 3, 2024, the Biden Administration published new regulations that will change the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing. The rule will become effective on November 1, 2024. Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover costs for emergency care for lawfully present immigrants who remain ineligible for Medicaid as well as for undocumented immigrants.

State Funded Coverage

As of June 2024, 12 states plus D.C. provide comprehensive state-funded coverage for children regardless of immigration status (Figure 5) . These states include California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. By 2025,  Colorado  and  Minnesota  plan to offer state-funded Medicaid-like coverage to income-eligible children regardless of immigration status. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of June 2024, six states  (California, Colorado, Illinois, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status (Figure 6) . Some additional states  cover  some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits. Maryland and Minnesota have also indicated plans to extend coverage to adults.

Data suggest that state coverage options for immigrants make a difference in their health coverage and health care access and use . The 2023 KFF/LA Times  Survey of Immigrants  shows that immigrants residing in states with more expansive coverage policies for immigrants are less likely to be uninsured compared to their counterparts living in states with less expansive coverage policies.  California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a  34%  decline in uninsurance rates. Similarly, a decline in uninsurance rates. Similarly, a  study  found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care and  improved outcomes  including increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated with  reduced postpartum care  utilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to be  less than half  the per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California could  reduce poverty  among noncitizen immigrants and their families.

Enrollment Barriers

Among immigrants who are eligible for coverage, many remain uninsured because of a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Research suggests that changes to immigration policy made by the Trump Administration contributed to growing fears among immigrant families about enrolling themselves and/or their children in Medicaid and CHIP even if they were eligible. In particular, changes to the public charge policy likely contributed to decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children. The Biden Administration reversed many of these changes, including the changes to public charge policy, and has increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty or an incorrect understanding about how use of non-cash assistance programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears .

Although the majority of immigrants are working, noncitizen immigrants, particularly those who are likely undocumented, have high uninsured rates due to more limited access to both public and private coverage. Federal legislation has been proposed that would expand immigrant eligibility for health coverage, though there is no clear path to passage in Congress. In the absence of federal action, some states are filling gaps in access to coverage for immigrants. However, many remain ineligible for any coverage options, contributing to barriers to access and use of care. Those eligible for coverage also face an array of barriers to enrollment, including fear and confusion about eligibility. The Biden Administration has made changes to public charge policies that are intended to reduce fears of enrolling in health coverage and accessing care and increased funding for outreach and enrollment assistance, which may help eligible immigrant families enroll and stay enrolled in coverage. However, immigrants continue to have significant confusion around public charge rules highlighting the importance of outreach and enrollment assistance , including community-led efforts, to rebuild trust and reduce fears among immigrant families about accessing health coverage and care.

KFF analysis of 2022 American Community Survey (ACS) 1-year Public Use Microdata Sample.

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KFF/LA Times Survey of Immigrants (April 10 – June 12, 2023).

Lawfully present immigrants are those who said they are not a U.S. citizen, but currently have a green card (lawful permanent status) or a valid work or student visa; likely undocumented immigrants are those who said they are not a U.S. citizen and do not currently have a green card (lawful permanent status) or a valid work or student visa. These immigrants are classified as “likely undocumented” since they have not affirmatively identified themselves as undocumented.KFF analysis of 2022 American Community Survey (ACS) 1-year Public Use Microdata Sample.

The estimate of the total number of noncitizens in the US is based on the 2022 American Community Survey (ACS) 1-year Public Use Microdata Sample (PUMS). The ACS data do not directly indicate whether an immigrant is lawfully present or not. We draw on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. Al. 1 , 2 This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to ACS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see the Technical Appendix B .

• Racial Equity and Health Policy
• Access to Care

Also of Interest

• Understanding the U.S. Immigrant Experience: The 2023 KFF/LA Times Survey of Immigrants
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants