What is Medicare’s Community Health Integration (CHI) and Who Qualifies?

Introduction

If you are managing a health condition and real life is getting in the way of care, Community Health Integration may help. CHI is a Medicare service that focuses on non medical needs that affect your care, like getting to appointments, understanding instructions, or finding safe food and housing resources. The goal is simple. Remove obstacles so your doctor can diagnose and treat you effectively.

What CHI Is

Community Health Integration (CHI) is person-centered support that addresses the social and practical needs connected to your medical care. It can include a thorough assessment to understand your unique situation, coordination between you and your care team, health education, patient self-advocacy training, help navigating the healthcare system, and emotional support. At Understood Care, a clinician is always available when you need one to ensure your plan of care stays on track. These services are designed to make it easier to follow the recommendations your clinician provides, and once you start, you can receive CHI every month.

Who Qualifies

Core eligibility

You may qualify when your clinician identifies social needs that significantly limit their ability to diagnose or treat the problem addressed in your visit. Examples include transportation barriers, food insecurity, unsafe housing, language or literacy challenges, and other factors that make care difficult. CHI is meant to resolve those needs so medical care can proceed.

Required initiating visit

Before CHI begins, you need an initiating visit with the practitioner who will oversee your care. This is usually an office visit where your medical needs are addressed and any unmet social needs are identified. In some cases, a yearly wellness visit can serve as the initiating visit if it documents social needs that could prevent you from following your prevention plan. The initiating visit is billed separately, as required by the Centers for Medicare & Medicaid Services.
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Understood Care makes this process simple by handling your initiating visit over the phone or through video, so there’s no need to travel or attend in person. Our professional nurses and advocates are trained to provide advanced support remotely, ensuring you receive high quality, personalized care from home. If you have a Medicare supplemental plan, you pay $0 out of pocket for this service. Learn more at https://understoodcare.com/pricing.

Consent and one billing practitioner per month

Your consent is required before services begin. Understood Care is free for most patients with Medicare. If there is any cost, we will tell you before your first session and you will never receive a surprise bill. Only one practitioner can bill CHI for you each month. Learn more at https://understoodcare.com/pricing‍

What CHI Includes Each Month

CHI is flexible and tailored to your needs. With Understood Care, you have a team of Advocates and clinicians supporting you.Common elements include

1. A person centered assessment to understand your goals, strengths, and barriers
2. A care plan focused on resolving the specific barriers that affect your medical care
3. Coordination with clinicians, pharmacies, and community programs
4. Coaching on how to ask questions and advocate for yourself at visits
5. Navigation training so you can use portals, schedule appointments, and understand referrals

Not every element is required every month. Your team provides what is reasonable and necessary for you at that time.

Who Provides CHI

CHI is delivered by Understood Care using trained auxiliary personnel such as patient advocates, community health workers, and registered nurses, under the general supervision of the practitioner who billed the initiating visit. All personnel are employed by Understood Care and coordinate directly with your clinic. Understood Care performs all documentation of activities and time.

How CHI Is Delivered

With Understood Care, Community Health Integration is delivered by phone and video, so you receive high quality, personalized support from the comfort of your home. These services are classified as care management outside the Medicare tele-health list and can be covered when furnished through telecommunications technology.

Costs With Original Medicare

After you meet the Part B deductible, you typically pay 20 percent coinsurance for CHI. Understood Care provides the clinician and will review any costs with you before your first session, with no surprise bills. For current details and examples, visit https://understoodcare.com/pricing.

Relationship to Social Determinants of Health Screening

Many people first learn about CHI during a social determinants of health risk assessment. This is a brief screening that checks for non medical needs like food, transportation, or housing issues. If needs are identified, you may be referred for CHI and or Principal Illness Navigation.

CHI Versus Other Medicare Care Management Services

It helps to know how CHI compares to related services.

• Principal Illness Navigation PIN supports people with one serious, high risk condition that is expected to last at least three months and may require frequent plan adjustments or caregiver support. CHI focuses on resolving non medical barriers that limit your ability to follow medical care. Some people receive both, as long as time is not double counted and services address different needs.
• Chronic Care Management and Principal Care Management focus on medical coordination and care plans for chronic conditions. These may be used with CHI when appropriate, again without double counting staff time.

Billing Notes You May Hear From Your Clinic

You do not need to know billing codes to receive help. They can be useful when speaking with billing staff. Understood Care will share any information you want, including codes, estimates, and documentation, with full transparency.

• Clinicians bill CHI using national HCPCS codes. G0019 describes the first 60 minutes in a month and G0022 describes each additional 30 minutes.
• Rural Health Clinics and Federally Qualified Health Centers can provide CHI. CMS materials explain how these centers report CHI and other care management services.

How to Get Started

• Call (646) 904-4027 or sign up at https://app.understoodcare.com/
• We will schedule an initiating call to address the medical problem affected by your social needs. You should bring a short list of barriers and goals.
• Give consent. Understood Care will confirm your coverage and any costs and introduce your CHI team, including the overseeing clinician and dedicated advocates.
• Understood Care will also keep a simple record of calls, visits, and changes so we can tailor support each month.

Community Health Integration (CHI): Frequently Asked Questions

• What is Community Health Integration (CHI)?
  Community Health Integration, or CHI, is a Medicare service that focuses on the non medical parts of your life that affect your ability to get care. It addresses barriers such as transportation, food access, housing safety, language or literacy challenges, and difficulty navigating the healthcare system. The purpose is to remove obstacles so your clinician can diagnose and treat you effectively and you can follow the plan.
• How does CHI help me in everyday life?
  CHI provides person centered support that looks at your goals, strengths, and barriers and builds a practical plan around them. It can include a detailed assessment of your situation, coordination with your clinicians and pharmacy, connections to community programs, coaching to help you ask questions and speak up about your needs, and training to use tools like patient portals and appointment systems. At Understood Care, you also have access to clinicians who help make sure your medical plan and your real life supports stay in sync.
• Who qualifies for CHI under Medicare?
  You may qualify if your clinician identifies social needs that significantly limit their ability to diagnose or treat the condition addressed in your visit. Examples include not having reliable transportation to appointments, not having enough food, living in unsafe or unstable housing, facing language or literacy barriers, or dealing with other non medical issues that make it hard to follow a care plan. CHI is designed to address those needs so you and your clinician can move forward with treatment.
• What is an initiating visit and why is it required?
  Before CHI can start, Medicare requires an initiating visit with the practitioner who will oversee your care. This visit usually happens in a medical appointment where your health issue is evaluated and your social needs are identified. In some cases, a yearly wellness visit can serve this purpose if it documents social needs that could interfere with your prevention or treatment plan. The initiating visit is billed separately, as required by the Centers for Medicare and Medicaid Services.
• How does Understood Care handle the initiating visit?
  Understood Care makes the process easier by completing the initiating visit by phone or video instead of requiring an in person trip. During this visit, a clinician addresses the medical problem, reviews your social needs, and confirms whether CHI is appropriate. Professional nurses and advocates are trained to provide advanced support remotely so you receive personalized care from home. If you have a Medicare supplemental plan, you typically pay zero dollars out of pocket for this service, and any potential cost is explained up front.
• Do I need to give consent and how often can CHI be billed?
  Yes. Your consent is required before CHI services begin. Understood Care explains coverage and any possible costs before your first session, and you will not receive surprise bills. Medicare allows only one practitioner to bill CHI for you each month, so you will have a single overseeing practitioner for that period, even though you may interact with several members of the support team.
• What does CHI include each month?
  Each month, CHI is tailored to what you need at that time. Common elements include a person centered assessment that reviews your goals and barriers, a care plan focused on the non medical obstacles that affect your treatment, coordination with clinicians, pharmacies, and community programs, coaching on how to ask questions and advocate for yourself during visits, and navigation training so you can use patient portals, schedule appointments, and understand referrals. Not every element has to happen every month. Your team decides what is reasonable and necessary for your situation.
• Who provides CHI services through Understood Care?
  At Understood Care, CHI is delivered by trained auxiliary personnel such as patient advocates, community health workers, and registered nurses. They work under the general supervision of the practitioner who completed your initiating visit. All of these personnel are employed by Understood Care and coordinate directly with your clinic. Understood Care keeps complete documentation of activities and time so your services are accurately recorded for Medicare.
• How are CHI sessions delivered?
  With Understood Care, CHI is delivered by phone and video, which means you can receive support from home rather than traveling to a clinic. Medicare classifies CHI as care management that can be furnished through telecommunications technology outside the usual tele health visit list, so it can still be covered even when it is not an in person visit.
• What does CHI cost with Original Medicare?
  With Original Medicare, once you have met your Part B deductible, you typically pay coinsurance for CHI services. Understood Care supplies the clinician and the team, confirms your coverage, and reviews any expected costs before your first session. Many patients with a Medicare supplemental plan pay nothing out of pocket. Understood Care also offers clear pricing information so there are no surprise charges.
• How does CHI relate to social determinants of health screening?
  Many people first hear about CHI after a social determinants of health (SDOH) risk assessment. This screening asks brief questions about non medical factors such as food access, transportation, housing safety, and financial strain. If that screening identifies needs that could interfere with care, your clinician may recommend CHI, Principal Illness Navigation, or both, to address those needs in a structured way.
• What is the difference between CHI and Principal Illness Navigation (PIN)?
  Principal Illness Navigation is designed for people with one serious, high risk condition that is expected to last at least three months and may need frequent plan adjustments, care coordination, or caregiver support. It focuses more on navigating a specific illness and its treatment. CHI, on the other hand, focuses on resolving non medical barriers such as transportation, food, housing, or navigation gaps that affect how you follow your clinician’s plan. Some people receive both services at the same time, as long as the time spent is not counted twice and each service addresses a different type of need.
• How does CHI relate to Chronic Care Management and Principal Care Management?
  Chronic Care Management and Principal Care Management focus on medical coordination for one or more chronic conditions. They involve creating and updating care plans, reviewing medicines, and tracking medical follow up. CHI complements these services by targeting the social and practical barriers that stand in the way of medical care. When appropriate, CHI can be used along with these other care management services, as long as staff time is not double counted.
• Why might I hear about billing codes like G0019 and G0022?
  You do not need to know billing codes to receive CHI, but sometimes billing staff or insurance representatives mention them. Clinicians bill CHI using national HCPCS codes. One code is used to describe the first block of time in a month and another code is used for additional time. Rural Health Clinics and Federally Qualified Health Centers can also provide CHI, and the Centers for Medicare and Medicaid Services gives them specific instructions on how to report these services. Understood Care can share any billing information you want your clinic to have, including codes and documentation, so everything is transparent.
• How do I start CHI with Understood Care?
  To get started, you can call Understood Care at (646) 904 4027 or sign up at https://app.understoodcare.com. The team will schedule an initiating call with a clinician to review the medical problem that is being affected by your social needs. During that call, you can describe your main barriers and goals. After you give consent, Understood Care confirms coverage and any costs, introduces you to your CHI team, and begins monthly support. Your team keeps a simple record of calls, visits, and changes so services can be adjusted as your life and health needs evolve.
• How can CHI work together with support for medication side effects and other services?
  If you are dealing with issues like neuropathy medication side effects or difficulty affording medicines, CHI can help by connecting you to related Understood Care services. Your advocate and clinician can coordinate side effect tracking, communication with your prescribers, and help with coverage questions while CHI focuses on transportation, food access, housing supports, and navigation tasks that make it easier to follow treatment. This creates a more complete support system that addresses both your medical plan and the day to day realities that affect your ability to carry it out.

Related Understood Care pages

These resources explain side effect management and coverage in plain language.

Covered by Medicare and most insurance
https://understoodcare.com/pricing

References

External Sources

• Medicare.gov community health integration services coverage page
  https://www.medicare.gov/coverage/community-health-integration-services
• Medicare.gov social determinants of health risk assessment coverage page
  https://www.medicare.gov/coverage/social-determinants-of-health-risk-assessment
• CMS Health Related Social Needs Frequently Asked Questions, updated 2025
  https://www.cms.gov/files/document/health-related-social-needs-faq.pdf
• CMS CY 2024 Medicare Physician Fee Schedule Final Rule Fact Sheet
  https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule
• CMS Transmittal R12419CP listing new HCPCS G codes including G0019 and G0022
  https://www.cms.gov/files/document/r12419cp.pdf
• CMS MLN Booklet Information for Rural Health Clinics, July 2025
  https://www.cms.gov/files/document/mln006398-information-rural-health-clinics.pdf
• CMS MLN Booklet Federally Qualified Health Center, 2025
  https://www.cms.gov/files/document/mln006397-federally-qualified-health-center.pdf
• Medicare.gov principal illness navigation services coverage page
  https://www.medicare.gov/coverage/principal-illness-navigation-services‍

This content is for educational purposes only and should not replace professional medical advice. Always consult with your healthcare provider for personalized care.