The Law Says Pay Them; the Rules Decide How: Legislation, Regulation, and the Meaning of a Community Health Worker Coverage Statute
Student Name
Doctor of Nursing Practice Program, Aspen University
DNP870: Health Policy, Advocacy, and Partnerships
Instructor Name
Month Day, Year
The Law Says Pay Them; the Rules Decide How: Legislation, Regulation, and the Meaning of a Community Health Worker Coverage Statute
Advocates often celebrate when a bill is signed, but a statute usually sets goals and authority while leaving the details to an executive agency. Those details, written in regulations, determine who benefits, how much is paid, and what the program actually does. This paper follows a composite state statute requiring Medicaid coverage of community health worker services from enactment into rulemaking, identifies the decisions the statute leaves to regulation, and shows where nurses can participate.
What the Statute Says
The enacted statute, following the bill traced in the previous module, is brief. It orders Medicaid to pay for the work of certified community health workers once a licensed clinician has recommended it, establishes a two-year pilot in three regions, requires the agency to adopt certification standards, and requires an evaluation report to the legislature. It authorizes the agency to adopt rules to implement the program. It does not say how workers are certified, which services are covered, how much they are paid, who can bill, or how outcomes will be measured.
Why Legislatures Delegate
Legislatures delegate details to agencies for practical reasons: agencies have technical expertise, can adjust rules as experience accumulates, and can manage complex payment systems that statutes cannot anticipate. Longest (2016) describes rulemaking as a central part of policy implementation, in which agencies translate legislative intent into operational rules, often with considerable discretion, and in which affected parties can participate through public comment. The same delegation that makes implementation workable also means that the program's real shape is decided by people who were not elected and in a process few advocates follow.
The Decisions Left to Regulation
The Medicaid agency's rules must answer at least six questions. Certification: how many hours of training, in what competencies, and whether experienced workers can be grandfathered. Covered services: whether coverage includes health education only or also help with housing, food, and transportation. Billing: whether individual workers, community organizations, clinics, or managed care plans bill for services, and under which codes. Payment: the rate per unit of service, which affects whether organizations can pay a living wage. Supervision: who must supervise workers and how. Evaluation: which measures the agency will collect for the legislature's report.
Each choice shapes the program. A research study of community health worker wages from 2010 to 2021 found that wages rose by $2.42 more per hour in states with certification programs than in states without them, while neither certification nor Medicaid reimbursement policy affected turnover (Jones et al., 2022). The statute created a program; the certification and payment rules will decide whether anyone can afford to work in it. A demanding certification with no pathway for experienced workers could exclude the trusted community members the program depends on, while a low payment rate could make participation unsustainable for community organizations.
The Federal Layer
State Medicaid programs also operate under federal rules. The state must also send the federal Medicaid agency a state plan amendment describing the new services, providers, and payment methods, and federal approval is required before federal matching funds flow. Federal regulations permit states to cover preventive services recommended by a physician or other licensed practitioner and provided by practitioners who are not themselves licensed, which is the pathway many states use for community health worker services. The state's rules must fit that federal framework, which can narrow the options the statute seemed to leave open.
Rulemaking and Where Nurses Can Participate
State administrative law requires the agency to publish proposed rules, accept public comment for at least 30 days, respond to significant comments, and then adopt final rules. Many agencies also convene advisory groups before drafting. Nurses can participate at several points: serving on the advisory group, submitting written comments on the proposed rules, testifying at public hearings, and organizing community health workers and patients to comment. Comments are most effective when they are specific, supported by evidence, and propose alternative language. Rodriguez (2022) argues that sustainable financing, including Medicaid reimbursement, is essential to expanding the community health worker workforce, which gives nurses a rationale for comments that press for adequate rates and inclusive certification.
A Sample Comment
A nurse commenting on the proposed certification rule might write: "The proposed rule requires 160 hours of classroom training for all applicants. I recommend adding a pathway allowing workers with at least 2,000 hours of documented community health work in the past three years to qualify through a competency assessment. Without such a pathway, the pilot regions will lose experienced workers whose community trust is the basis of the program's effectiveness." The comment is specific, proposes language, and connects to the program's purpose.
When Rules Drift From Legislative Intent
Regulations can also move a program away from what the legislature intended, sometimes without anyone deciding to do so. If the agency, anxious about fraud, requires prior authorization for every community health worker visit, the paperwork could consume the time the statute meant to spend with patients. If the rate is set at the level of a brief health education session rather than an hour of navigation and home visits, organizations may limit services to what the rate covers. Legislatures have tools to respond: oversight hearings, the evaluation report the statute requires, and, in some states, legislative committees that review proposed rules. Nurse advocates can use each of these, bringing evidence from practice about how the rules are working. Tracking implementation after enactment, and returning to legislators with specific findings, completes the policy cycle that begins with a bill.
Conclusion
The community health worker statute sets a direction and delegates the details. The Medicaid agency's rules on certification, services, billing, payment, supervision, and evaluation, shaped by federal requirements, will determine what the program becomes. For nurse advocates, the signing ceremony is the midpoint of the work, not the end, and the comment period is where much of the program's meaning is still open to influence.
References
Jones, T. M., Jeung, C., Schulte, A., Lewis, C. M., & Maddox, P. J. (2022). Hourly wages and turnover of community health workers according to US state certification policy and Medicaid reimbursement, 2010-2021. American Journal of Public Health, 112(10), 1480-1488. https://doi.org/10.2105/AJPH.2022.306965
Longest, B. B., Jr. (2016). Health policymaking in the United States (6th ed.). Health Administration Press.
Rodriguez, N. M. (2022). Community health workers in the United States: Time to expand a critical workforce. American Journal of Public Health, 112(5), 697-699. https://doi.org/10.2105/AJPH.2022.306775
How this DNP 870 Module 2 example is structured
DNP870 Module 2 papers typically separate legislation from the regulations that decide its meaning. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example summarizes a statute, explains why legislatures delegate, lists the decisions left to regulation with evidence on their effects, adds the federal layer and shows how nurses participate in rulemaking.
DNP870 Module 2 questions, answered
What does DNP870 Module 2 usually ask for?
The module typically asks you to distinguish legislation from the regulations that implement it, often by following a law into rulemaking and showing how regulations shape its meaning. Aspen does not publish module deliverables, so your classroom's instructions govern.
What is the difference between a statute and a regulation?
A statute is a law passed by the legislature that sets goals and grants authority. A regulation is a rule adopted by an executive agency under that authority to specify how the law will be carried out.
How can nurses influence regulations?
By joining advisory groups, submitting specific written comments with evidence and proposed language during public comment periods, testifying at hearings and mobilizing affected communities to comment.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.