What is Medicare’s Principal Illness Navigation (PIN)?

Introduction

If you are living with a serious condition, it can be hard to keep track of appointments, referrals, test results, and day to day needs that affect care. Medicare’s Principal Illness Navigation, often shortened to PIN, is a monthly care management service that helps you and your caregiver understand the condition, follow the treatment plan, and overcome barriers that get in the way of your care. PIN is delivered by trained personnel such as patient navigators or peer support specialists working with your Medicare practitioner.

Who qualifies and when PIN helps

PIN is designed for people who have a serious high risk condition expected to last at least three months and that places them at significant risk of hospitalization, nursing home placement, a sudden worsening of symptoms, functional decline, or death. Examples include cancer, HIV, and substance use disorder among others. Before you start PIN, you must have an initial visit with the practitioner who will oversee the service. After that first visit, navigation can continue monthly as long as it is needed.

What counts as a serious high risk condition

A qualifying condition is one your practitioner judges to be serious and high risk, requires creation or monitoring of a treatment plan, and benefits from ongoing help coordinating care and addressing obstacles that interfere with diagnosis or treatment.

What a navigator does each month

Navigation focuses on the real tasks that move care forward. A navigator can explain the treatment plan, help schedule and prepare for visits, coordinate with your care team, promote self advocacy, and connect you with community resources that support the plan of care. The exact activities vary based on your needs. Not every element is required every month. To find out more ways we can help you, reach out to Understood Care at (646) 904-4027 or sign up at https://app.understoodcare.com/ to speak with a care advocate today.

What services are included

Core elements of PIN

Under Medicare’s policy, PIN includes person centered assessment and planning, health system coordination, promoting patient self advocacy, and facilitating access to community based resources when barriers are interfering with the practitioner’s diagnosis and treatment.

PIN peer support

Medicare also pays for a peer support version of PIN when trained peers with lived experience help you navigate care for the same type of serious condition. Coverage, supervision, and documentation rules mirror standard PIN with codes dedicated to peer support time.

How PIN is provided and by whom

Who can provide PIN

PIN services are generally furnished by auxiliary personnel such as patient navigators or peer support specialists working incident to the practitioner’s services under general supervision. These personnel, including Understood Care advocates, can be directly employed or contracted through community organizations if Medicare incident to rules are met. When eligible, these services can be provided free under Medicare Community Health Integration Services or Medicare Principal Illness Navigation Services. The billing practitioner remains responsible for oversight and for verifying documentation in the medical record.

Supervision and consent

Your Understood Care practitioner obtains your consent before services start and renews it annually or when the billing practitioner changes. Consent may be verbal or written as long as it is documented. The practitioner or auxiliary personnel should explain that cost sharing applies and that only one practitioner can bill PIN for a given condition per month.

How billing and cost sharing work in Original Medicare

Codes and time thresholds

Medicare pays for PIN using monthly time based HCPCS G codes. There is a base code for at least sixty minutes of work in a calendar month and an add on code for each additional thirty minutes. There are parallel base and add on codes for peer support. These codes began January 1, 2024.

Cost to you

In Original Medicare, after you meet the Part B deductible, you typically pay twenty percent of the Medicare approved amount for PIN. With a supplemental, you pay $0 out of pocket. Learn more at https://understoodcare.com/care-types/lower-costs-of-medication

Special notes for Rural Health Clinics and Federally Qualified Health Centers

Starting January 1, 2025, RHCs and FQHCs may bill the individual PIN and other care coordination codes at national non facility fee schedule rates. For sites that need more time to update their systems, Medicare allows continued use of G0511 through September 30, 2025, after which facilities must use the individual codes.

How PIN works with other Medicare services

PIN can be combined with other care management when rules allow, and it often pairs well with a Social Determinants of Health risk assessment performed with a qualifying visit. Medicare also created Community Health Integration, a separate monthly service focused on resolving specific unmet needs that limit diagnosis or treatment. Your practitioner can help decide which mix best fits your situation.

Why patient navigation matters

Research shows navigation improves participation in screening, shortens time from abnormal tests to diagnosis and treatment, and enhances patient experience, especially for underserved populations. While much of the evidence comes from cancer care, the same navigation skills apply across serious conditions.

Getting started

The easiest way to see if you qualify for PIN and begin getting the care you deserve is to connect with an Understood Care advocate today. Call us at (646) 904-4027 or sign up at https://app.understoodcare.com/ to speak with a care advocate who will guide you every step of the way. Understood Care can:
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1. Confirm if your condition qualifies for PIN and explain how the program works
2. Set up the initiating visit to review your treatment plan and discuss navigation needs
3. Ensure your consent is documented and you know how to reach your navigator between visits
4. Show you how to keep a simple list of questions, appointments, and barriers to share with your navigator
5. Answer questions about any bills and review coinsurance or secondary coverage that may help

Frequently asked questions

• ‍Can I receive PIN for more than one condition
  Yes. You can receive PIN for more than one serious condition at the same time as long as the services are for different conditions and not furnished by the same practitioner for the same month. Medicare‍
• Is PIN a tele-health service
  Yes. Through Understood Care, PIN services are handled completely over the phone, so there’s no need to travel or attend in-person appointments. Our professional nurses and advocates are specially trained to provide advanced support remotely, ensuring you receive high-quality, personalized care from the comfort of your home. Call us at (646) 904-4027 or sign up at https://app.understoodcare.com/ to get started today.‍
• What should be documented
  Through Understood Care, all PIN activities are fully documented and captured in your medical record. This includes the time spent, the activities performed in relation to the practitioner’s plan of care, and any unmet social needs addressed. Your medical record is reviewed by the billing practitioner to ensure accuracy and continuity of care.

References

• Medicare.gov. Principal Illness Navigation Services Coverage
  https://www.medicare.gov/coverage/principal-illness-navigation-services
• Centers for Medicare and Medicaid Services. CY 2024 Medicare Physician Fee Schedule Final Rule Summary MLN Matters MM13452
  https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdf
• Centers for Medicare and Medicaid Services. Health Related Social Needs FAQ for CHI and PIN
  https://www.cms.gov/files/document/health-related-social-needs-faq.pdf
• Centers for Medicare and Medicaid Services. Federally Qualified Health Centers Center, 2025 updates for care coordination billing
  https://www.cms.gov/medicare/payment/prospective-payment-systems/federally-qualified-health-centers-fqhc-center
• Centers for Medicare and Medicaid Services. CY 2025 Medicare Physician Fee Schedule Final Rule Fact Sheet
  https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule
• Systematic review. Patient Navigation in Cancer Treatment
  https://pmc.ncbi.nlm.nih.gov/articles/PMC11063100/
• Systematic review. Effectiveness of Patient Navigation to Increase Cancer Screening
  https://pmc.ncbi.nlm.nih.gov/articles/PMC7573022/

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