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.

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.

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. ‍

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/care-types/lower-costs-of-medication.

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.

Frequently Asked Questions

• ‍Can CHI help me if I have multiple needs
  Yes. Your Understood Care team can address the needs that are most limiting your care and adjust the plan as new barriers are identified.‍
• Do I need a new referral every month
  No. After the initiating visit and consent, services can continue monthly as long as they are reasonable and necessary.‍
• Is CHI covered if I only talk by phone
  Yes. CHI can be furnished using telecommunications technology. It is still covered as care management.

References

• 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.