Medicare Reimbursement
Medicare Reimbursement
While CHWs are not directly recognized Medicare providers, their services may be reimbursed when furnished under eligible practitioners’ supervision through Community Health Integration (CHI) and/or Principal Illness Navigation (PIN).
Community Health Integration (CHI) and Principal Illness Navigation (PIN) Services Under Medicare
Overview
Beginning January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) established Medicare reimbursement for Community Health Integration (CHI) and Principal Illness Navigation (PIN) services. These services recognize the important role that Community Health Workers (CHWs), Community Health Representatives (CHRs), and other auxiliary personnel play in helping Medicare beneficiaries address barriers to health, navigate health and social service systems, and manage ongoing health conditions.
CHI and PIN services are intended to complement, not replace, clinical care. They support whole-person care by addressing health-related social needs, improving coordination across providers and community resources, and helping individuals follow their care plans.
Organizations employing CHWs or CHRs may be able to incorporate these services into their care delivery model when working in collaboration with a Medicare-enrolled billing practitioner.
While Medicare recognizes these services nationwide, organizations should ensure they understand Medicare requirements before implementing them.
Readiness Assessment
Implementation
Organizations preparing to provide CHI or PIN services should use the guidance below to develop workflows, define team roles, establish documentation practices, and meet Medicare implementation requirements.
Billing
Organizations providing CHI or PIN services should use the guidance below to understand Medicare billing requirements, including practitioner oversight, documentation, HCPCS coding, and compliance with current CMS policies.
For more information, please review the Frequently Asked Questions section on the Centers for Medicare & Medicaid Services (CMS) website: https://www.cms.gov/files/document/health-related-social-needs-faq.pdf