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Changes to 2024 Medicare Physician Fee Schedule for CHI Services

Policy Cheat Sheet

April 08, 2024

The 2024 Medicare Physician Fee Schedule (PFS) Final Rule, as developed by the Centers for Medicare & Medicaid Services (CMS), went into effect on January 1, 2024. The PFS includes Medicare Part B coding and payment changes for certified or trained auxiliary personnel—including community health workers—under the direction of a Medicare-billing practitioner, to be reimbursed for providing a new set of services called Community Health Integration (CHI). Such services represent the first time that Medicare services were designed to include a specific role for community health workers (CHWs).

What are Community Health Integration Services?

Per CMS, CHI services are designed to “address unmet social determinant of health (SDOH) needs that affect the diagnosis and treatment of the patient’s medical problems.” CHI services must be directly related to SDOH that have been documented in an initiating visit as affecting a patient’s treatment plan. Services include:

  • Conducting a person-centered assessment, facilitating goal setting, and providing tailored support to patients according to the provider’s treatment plan.
  • Coordinating patient services from a range of provider types (e.g., healthcare, home- and community-based services, social services), facilitating access to social services, and communicating with providers about patient goals, needs, and preferences.
  • Coordinating care transitions, including follow-up after emergency department visits or discharges from hospitals or skilled nursing facilities.
  • Supporting patients to participate in medical decision-making and use provider health education to help identify individual patient goals and preferences.
  • Building patient self-advocacy skills to promote more effective treatment.
  • Helping the patient navigate healthcare systems, including identifying providers and making appointments.
  • Assisting with social and emotional supports.
  • Drawing on lived experience to support patients to meet treatment goals.

These services may be provided in-person or virtually, with services in both settings reimbursed at the same rate. Only one auxiliary personnel may bill for CHI services in each month to avoid fragmentation and create a single patient point of contact for these services. Medicare Part B deductible and cost-sharing requirements apply to CHI services.

Structure and Rate for Community Health Integration Services

The PFS outlines Healthcare Common Procedure Coding System (HCPCS) codes and descriptors for these services. The rates for these services vary based on region and on whether the service is provided in a facility that would receive a separate facility fee. Notably, there is no limitation on the frequency of these services.

  • G0019: Services performed by certified or trained auxiliary personnel, including a CHW, under the direction of a physician or other practitioner; 60 minutes per calendar month. The national payment amount is approximately $79 (non-facility) or $49 (facility).
  • G0022: CHI services, each additional 30 minutes per calendar month. The national payment amount is approximately $49 (non-facility) or $34 (facility).
  • G0511: This general care management code is used by federally qualified health centers and rural health centers to bill for each CHI service. The national payment amount is approximately $77.

State Medicaid agencies have the option to add these HCPCS codes as Medicare crossover codes to be covered by Medicaid benefits.

How CHWs Will Receive Payment under Medicare

A Medicare-billing practitioner must have an initiating patient visit (during an evaluation and management visit or an annual wellness visit) to conduct an assessment for SDOH needs using an evidence-based assessment tool. Then, CHI services may be delivered under the general supervision of the billing practitioner.

Only Medicare-billing providers and practices can bill for CHI services. The Medicare-billing practitioner can arrange for CHI services to be delivered by internal staff or by personnel employed by community-based organizations (CBOs) that contract with the billing practitioner or practice to provide these services. CHWs as well as CBOs that may employ CHWs cannot be directly reimbursed by Medicare.

Examples of CBOs identified in the rule include “community-action agencies, housing agencies, area agencies on aging, centers for independent living, aging and disability resource centers or other non-profits that apply for grants or contract with healthcare entities to perform social services.” Additionally, community care hubs are “backbone organizations” that can coordinate administrative functions and manage funding streams for a network of CBOs. These hub organizations may contract with healthcare entities on behalf of multiple CBOs.

A November 2023 U.S. Department of Health and Human Services Call to Action stated that “providers should consider working with hubs and CBOs that employ community health workers and other appropriate auxiliary staff to furnish community health integration and illness navigation services for patients with Medicare as required under the 2024 Physician Fee Schedule.”

If contracting with a CBO, the final rule states that “there must be sufficient clinical integration” between the provider entity and the CBO. Clinical integration would mean that there is documentation of the CHI plan and services in the electronic health record of the billing provider, as well as communication between the CBO and the billing provider.

CHW Requirements for Providing Community Health Integration Services

The rule states that all CHWs who provide CHI services “must be certified or trained to perform all included service elements, and authorized to perform them under applicable State laws and regulations.” The final rule does not require a certain number of training hours, but instead defers to relevant state rules on CHW training and certification:

  • If a state does have CHW training or certification requirements, then auxiliary personnel must be certified and trained to provide all services part of CHI and authorized to perform them under applicable state laws and regulations.
  • If a state does not have CHW training or certification requirements, that state would need to establish training on the identified core competencies (which are based on the Community Health Worker Core Competency (C3) project) in order for CHWs to be able to deliver CHI services.

The Center for Health Care Strategies (CHCS) created this policy cheat sheet for the Community Health Worker Sustainability Peer Network, convened by the Association of State and Territorial Health Officials (ASTHO) through support from the Centers for Disease Control and Prevention (CDC). The CDC awarded funds to ASTHO for this project through the Strengthening Public Health Systems and Services Through National Partnerships (CDC-RFA-OT18-1802) cooperative agreement. The contents are solely the responsibility of CHCS and ASTHO and do not necessarily represent the official views of the U.S. Department of Health and Human Services/CDC.