What physicians should know about community health workers before Medicaid work requirements take effect

Beginning Jan. 1, 2027, most adults ages 19 to 64 enrolled through Medicaid expansion will have to document 80 hours a month of work, school, job training or community service, or show income of at least $580 a month, and report it at least every six months, to keep their coverage.

The requirement comes from the 2025 reconciliation law known as H.R. 1. The Congressional Budget Office projects it will lead about 5.2 million adults not to renew their benefits, on top of $324 billion in cuts.

CMS published the interim final rule June 1, 2026, and it took effect July 31. Nebraska began enforcing work requirements May 1, Georgia has run its own version since 2023, and Arkansas and Montana started tracking hours without penalties July 1. A 25-state suit seeking to block the rule was denied a pause in July, and the underlying challenge is still in court.

Colby Takeda, M.P.H., MBA, co-founded Pear Suite in 2021 and is the company’s CEO.

A registered community health worker, he built the company around the contracting, documentation and claims plumbing that lets community-based organizations get paid by health plans for community health worker services. Pear Suite raised a $7.6 million Series A in October 2025 and says it has helped about 3,000 frontline workers contract with plans.

More than 24 states now cover some form of community health worker service under Medicaid. Medicare has paid for community health integration services since January 2024 under codes G0019 and G0022, which a practice bills under general supervision after a physician identifies a social barrier at an initiating visit. Takeda says states and health plans are now routing redetermination outreach through that same workforce.

Medical Economics spoke with Takeda about where community health workers fit in the redetermination push, what they are and are not allowed to do, whether the outreach itself is billable, and what a primary care practice should be asking its state and its health plans before January.

Related content: Report: Self-pay patient encounters rose and Medicaid fell across all care settings

Our conversation, lightly edited for length and clarity, follows.

What does Pear Suite do, and how did the company get started?

We're really proud of what we've done at Pear Suite. I was originally in the public health field, doing work during COVID-19, and I recognized there was a big gap in the infrastructure for community-based organizations working on the social determinants of health.

Think about a church, a nonprofit, a community-based group going to homeless shelters. Even groups like libraries and community centers were doing work around food and housing and transportation, and there was just a big need.

A lot of these groups were working on paper and spreadsheets, or not even documenting their data around who they're helping, what their needs are and how they can help them navigate to resources.

So we thought, let's build something for them, built by community health workers for community health workers. We decided to start with documentation systems, but quickly realized they needed more. They needed billing support. They needed support getting contracts with health plans. They needed help with compliance, working in the health care system. This is the first time many of these groups have ever interacted with health plans and health systems.

So we ended up building what we call the back-end infrastructure for community-based care.

Everything from documenting a member's needs to documenting care plans, helping individuals navigate social resources and getting them connected to the health care system. How do we find a provider? All of that can be documented in our system.

What's great about Pear Suite is that it also aligns with billing and the new codes that have come out.

Pear Suite recognized a big gap in the ability for these community-based providers to get paid and compensated for their work. Since 2021, there have been new codes and new states that allow community health workers and other community-based providers to get reimbursed for their services.

Of course, you can't do that without submitting a claim. So we basically help organizations document the good work they're doing every day, submit it as claims and get compensated so they can sustain this work and expand their impact.

For physicians who aren't familiar with community health workers, how did you get into that work, and what does it look like day to day?

I was actually working in the senior industry and the aging space, helping seniors navigate the end of life and challenges around getting older, getting therapy, experiencing cognitive decline. It was interesting because in our setting it was all about how we help them live their best life as independently as possible.

That involves things like food and housing, getting social engagement to reduce isolation and loneliness, being able to transport yourself to physical or medical facilities and other spaces like your church or your community center. So we really wrapped around what we call whole-person care for these individuals and older adults.

That led me to doing more work in the community health space with community health workers, and to identifying that there was a big gap in this work.

What was fascinating is that every time I would connect with a physician or a clinician and tell them what I was doing around food and housing, it sometimes took a while for them to recognize that there are these individuals, what we call community health workers, who are doing this work, and they've been doing it for decades. It's not a new provider type.

These are individuals who have lived experience, who have an understanding of community resources, who can really build trust with individuals experiencing challenges around housing and food and transportation, and who are really good at solving those problems.

They sometimes go by different names. In some cases they're called care coordinators, other times they're advocates. In the Hispanic and Latino community, they're called promotores.

Despite them being around for decades, there hasn't been much integration between these community-based providers and clinicians, which is why we exist now.

We want to bridge those gaps and allow clinicians to partner alongside community health workers, and make it easier for them to send referrals to help individuals fill out SNAP benefits, or help them get housing by filling out Section 8 applications, or help them navigate transportation options so they can get to their provider at a reasonable time without having to skip appointments or end up in the ER.

Community-based providers are kind of everywhere. We're meeting them every day. They've been doing this work for decades, and this is the first time we're actually helping them get paid, but also helping them work alongside clinicians, sometimes in person in the clinic, but most times virtually or in people's homes.

What are you seeing in the states that have already started enforcing Medicaid work requirements, and what do you expect once the rest follow?

It's been really exciting to see how much community health workers are being leveraged for a lot of this work. This is something they're really skilled with, on a topic that's sensitive but so important to Medicaid members.

Redetermination is going to be really challenging, and we're already seeing some challenges from states like Nebraska, where they're already rolling this out. But I think there's a lot of opportunity to partner with trusted individuals, community health workers who have the knowledge and skills to address these challenges.

In some states we're seeing a lot of confusion. There are a lot of people getting involved in this work: the counties, the states, the Medicaid offices, health plans. Health plans are leveraging providers like clinicians to support with redetermination and work requirements reporting.

So the big question first is, what is the state's plan? Who's going to take the lead? Is there a timeline? Are there multiple layers, where the state goes first, they send out their letters, the letter has to be addressed by the family, and if not, the health plan steps in and sends out its own reminders?

They may be using their own systems, like texts or email or phone calls, or even some AI tools.

So understanding what a state's or a health plan's strategy is in addressing work requirements reporting or other redetermination reporting, and then what the role of community health workers could be.

Are they supplementing the in-house health plan staff? Are they coming in after and calling and following up with anyone who hasn't responded to initial attempts by the health plan or the city or the county?

It's been growing great. We've been in quite a few conversations with health plans to coordinate the role of community health workers, and some of them are taking a really big role in doing outreach, sometimes even before the health plan does it.

Just that awareness, the fact that they already have these relationships, has been so helpful for health plans to know that they can be a trusted partner in the redetermination process.

You've argued that people who are still eligible will lose coverage under H.R. 1 because no one reached them in time. Where does that break down, and who does it fall on?

Just like with other past experiences, with the COVID-19 pandemic and vaccinations, trusted information sources are so critical. Who are you getting information from, what are those sources and how do we follow through with them?

It's one thing to get information, whether it's on paper or by phone or email or text, but being able to follow through with it and actually complete whatever task is being asked is another thing.

A lot of the individuals we work with, a lot of Medicaid members, will be challenged by some of the steps and applications or online portals they have to navigate to actually complete the process and keep their coverage. We're worried about people for whom English is not their first language.

Others may have challenges with tech literacy and not be able to log on to the online portals that health plans or states are requiring them to upload their documentation to. Others are just afraid of other things right now, whether it be enforcement by ICE or other challenges with the health care system or the economy, and that's creating barriers for these individuals to access care or access resources.

At a time when other things are happening, giving them information or sharing information about themselves can be a risk, and I think they're fearful of that. So trust is so critical, and that's where community health workers can really step in.

They are trusted local individuals who have been doing this work for decades. They might be your fellow church members or your neighbors, or people you see at the nearby community center. So ensuring that they have the right information and can be trusted messengers of that information is so critical at this time.

When a community health worker sits down with someone to gather pay stubs or fill out a form, is that reimbursed by Medicaid?

There actually are some differences in state policy regarding what is reimbursable. Every state, when they created policy regarding Medicaid reimbursement for CHW services, may or may not have included language that would allow something like redetermination to be covered. So every state is navigating through either FAQs or webinars, educating existing providers on what is eligible and what isn't.

Some health plans have taken it upon themselves to infer or interpret the documentation in policy around what is eligible, or they're finding other ways to compensate CHWs.

That's one of the key things around community health workers. They've been doing work for free for decades, and this is the first time, with reimbursement, that they're actually able to get compensated for their time and energy and the value they're bringing to the health care system.

To all of a sudden take that away and assume that people will just do this for free, because that's part of their job description or part of their mission, is somewhat misguided.

So it's exciting to see CHWs being leveraged at this time. But I definitely encourage states and health plans and other county officials and public agencies to really consider what the value is that health plans can get from these community health workers, and how do we make sure we compensate them and value them properly, so we can really appreciate their time and energy in this space.

One exemption in H.R. 1 is for people considered medically frail, and physicians expect to be handed those forms. Do community health workers have a role there, or is that entirely on the primary care physician?

This is a really key distinction between community health workers and other provider types. Community health workers are seen as non-clinical in their ability, so they can't diagnose individuals, they can't prescribe anything, and they can't educate people on how to take their medications. Being sure we keep those guardrails and swim lanes clear is so critical.

In working with community health workers, other times it can go the opposite way, where clinicians sometimes think CHWs are admin assistants or can do office work and staple papers and hand out forms. Sometimes they will do that, but I think we want to make sure that we're always elevating people to the top of their license, and in this case certification, if there is certification for CHWs.

This has actually been one of the challenges to date, too. Every state has different requirements around the training and the backgrounds of CHWs to become approved to either bill for services or work in different settings, or work with health plans or health systems. So until we can get consensus around what those standards are, it'll be tough to nationalize this workforce in the way that other provider types have.

But we definitely want to be sure to keep CHWs focused on social challenges and social opportunities and resources, and finding ways to get people connected to different caregivers or care providers. One of the biggest things we do with health plans is just help people get to a PCP.

If you don't have a PCP, a lot of things like HEDIS measures, screenings and vaccinations can't happen. So if anything else, we always encourage our CHWs to ensure that each Medicaid member has a PCP, knows how to get in touch with them, feels comfortable with them and can schedule an appointment. If we can ensure that, then they're much more likely to engage in preventive measures and get care when they need it, in ways that don't rely on emergency rooms and other high-utilization services.

Can a physician's office work with community health workers directly, or does it have to go through a health plan? What would that take for a small independent practice?

CHWs have only recently been incorporated into many of these settings. I will say federally qualified health centers and some clinics have been using CHWs for quite a while, but not at the scale we're seeing now.

There are different models. Sometimes a clinic or a hospital system or other care setting will hire their own CHWs to work in house and be employed by the same entity. Other times it's just not feasible, both financially and because it takes a management team to hire and train and supervise CHWs, and they'd rather partner with existing CHWs in the community.

So first is, what's the setup, and what's the philosophy for how a provider wants to partner with or work with CHWs? Is it hiring their own? Is it getting contracted CHWs, or partnering with an existing organization that already has CHWs but is maybe more community-based?

Once you establish that philosophy, you can figure out how to operationalize it. How do we share data with them? How do we communicate with them? How do we make referrals to them? Is it directly through an organization, or is it through a hub? There's an exciting movement around community care hubs, the idea that maybe each individual organization doesn't have to have its own contract with the health plan or health system, but can work through one lead entity, and that lead entity serves as the matchmaker.

They can receive referrals from a health system or health plan and then pass them on to smaller organizations based on fit. Location, language, competencies, needs, priority populations: these are all ways you can prioritize the fit between a CHW and an appropriate community member.

But back to your question, health plans can certainly refer, and they've been using CHWs to do things like closing HEDIS gaps or addressing gaps in care that might lead to higher utilization, or not getting people the preventive screenings and measures that we know will help improve health care. But health plans aren't the only source. We're also seeing referrals from health systems, from EMS, from health departments, as well as from community-based organizations.

So you can imagine an individual going to the YMCA to get their diabetes prevention program, but if they have other challenges around housing, maybe the YMCA isn't fit to provide that navigation. They want to refer to a housing agency or housing group that can help them navigate a housing application.

So, referrals from all directions. Of course, the data sharing gets really exciting and complicated at the same time, because you have to figure out how to work across a documentation system that a health plan uses versus an EHR in a health system versus the state Medicaid program that the public agency is setting.

Community health worker programs ran on grant money for years, and Medicaid reimbursement is recent. How does the workforce survive Medicaid cuts?

For the most part, we haven't been seeing Medicaid reimbursement for CHW services being a target for potential cuts, even though Medicaid funding overall has gone down. There's been a high recognition and actually a low utilization, so it's a really small budget item in the overall budget for Medicaid programs and the ways a Medicaid office might be using its funding. So we haven't seen a reduction in this to date.

We have seen some states postpone the activation of a new benefit like the CHW benefit. Some states have pushed that back because of cuts to budget. But we've also seen a lot of states introduce Medicaid reimbursement for CHWs or other frontline providers like doulas and peer support specialists during this time. So it's been exciting to see.

There's a lot of excitement right now around redetermination and the need for CHWs to be involved in this process, and of course that is a way to maintain revenue from the federal government.

So that's an important piece of this. But also with rural health, the Rural Health Transformation funds, a lot of it has been going to these frontline workforces, which are so essential in rural and remote and frontier settings. So we're seeing a lot of investment into both the training and enablement and deployment of CHWs, despite some cuts to Medicaid, which is exciting.

I do want to also mention that Medicare also reimburses for CHW services, and the rates are actually pretty good. Unlike Medicare, Medicaid is managed at the local level, so we're seeing rates change across states.

We're seeing requirements and barriers to entry being different, so it depends where you're operating and what the makeup of the model is in that state, and that might change at the regional level as well.

We're seeing some health plans, even though the state might allow for reimbursement, maybe the health plan doesn't want to participate as much or heavily, or isn't advocating for external communities or organizations to be reimbursed, because they have their own internal CHWs and prioritize that method versus partnering with community-based organizations or nonprofits.

Pear Suite has helped 3,000 frontline workers contract with health plans. What outcome data are you able to show a plan to justify the spend?

Before, when we started this work, we were just providing software for these groups, and we quickly realized that giving them great software isn't enough to make them successful.

If they can't get a contract with the health plan, if they can't get credentialed with the Medicaid office, if they can't understand compliance and meet the audits, they're going to lose their contract immediately, if they can even get one to begin with.

So we've expanded our scope and do a lot of ongoing support for CHWs to ensure they can start working with a health plan and be successful and get paid, but also make sure that their work aligns with what the health plan wants. A lot of that is tied to quality. It's tied to compliance.

Because of that, we've actually taken on a role beyond just being a software technology provider. Health plans look to Pear to be really the guide and the coach to ensure high quality and do QA and do audits, so that anyone who's operating under us meets those standards. Essentially we're responsible. We have the contract with the health plan, we're responsible for the members' care, and therefore we have to ensure that anyone under our contracts or subcontractors is meeting these requirements.

So we are really taking on a lot of that risk.

But it also gave us an opportunity to dive in and help these providers become better, help them become more efficient with their time, help them make more money, help them ensure quality outcomes tied to things the health plan cares about.

We're seeing about 78% engagement across the board with CHWs working with the member to help them close their care gaps and helping them address needs around food, housing and transportation, so their willingness to actually complete tasks like enrolling in SNAP or getting their vaccinations completed or getting their annual wellness visits completed.

One health plan recently reported to us that when a CHW works with their members, they're three times more likely to see their PCP within six months. That is really valuable. It doesn't just result in fluffiness. It actually results in ROI and cost savings, as well as increased revenue for these health plans.

So we want to make sure we tie all of their work to things that the health plan cares about, which was a big challenge. A lot of these health plans speak a certain language that community-based organizations haven't understood to date. They haven't had to deal with everything from NPIs to Z codes to CPT codes, so helping to translate that for two different groups has been one of our big assets, and how we help support these community providers.

What should a primary care physician be doing between now and January?

Understanding what their local market's strategy is for helping to keep Medicaid members enrolled and in better benefits. Understanding what the county or the state is doing, because everyone's going to have a process.

A lot of states are already listing out their process online or documenting a timeline. Because the timeline starts in January, a lot of states are sending out documentation in September and October to get ready for that.

But also realizing that there might be groups on the ground, resources, community-based organizations that could be a great source of information and also technical support when it comes to helping someone fill out these forms, or get their work requirements in, or even find work to begin with.

A lot of community-based organizations offer volunteer opportunities or offer training in a form that can help meet the requirements needed to both get the education requirement checked off or actually find a job to begin with.

So I would definitely encourage physicians and clinics and different practices to reach out to the state and their health plan to understand what their strategy is, and then understand what local providers like community health workers could do to assist.

Is there anything I didn't ask about that physicians should keep in mind?

I just really encourage everyone to look into community health workers. There are probably already a lot of community health workers in your area.

These groups go by different names, like I mentioned, but they're so valuable and they're so essential to building that trust and closing key care gaps. They can really be a great partner for clinics and practices.

We're seeing such great results from CHWs when they're empowered and uplifted and valued. So I just encourage people to thank them for what they do, but also to find ways to work with them.

I think there are always solutions at play, and certainly if we can help, I'd be happy to as well.