Medicare Financing for CHW Services

In November 2023, the Centers for Medicare and Medicaid Services (CMS) released the CY 2024 Medicare Physician Fee Schedule (PFS). The final rule, effective January 1, 2024, includes policy changes for Medicare to authorize payment for Community Health Worker (CHW) services to address health-related social needs (HRSNs) under Community Health Integration (CHI) and Principal Illness Navigation (PIN) for the first time in history. There are also provisions to support Medicare providers contracting with community-based organizations (CBOs) or community care hubs (CCHs) to address HRSNs for priority populations. These codes are the first that are specifically designed to describe services involving community health workers, care navigators, and peer support specialists, and that allow these services to be provided by personnel employed by CCHs/CBOs under the general supervision of the billing practitioner. The PA CHW Collaborative was pleased to provide comments to CMS on the proposed rule back in October, specifically about these topics which can be found here.

    Medicare PFS (Part B)

    An opportunity for Community Health Workers

    This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute.

    The Basics

    1.  Community Health Integration (CHI) services (Part B)
    2.  Must be ordered by “billing provider” during an “initiating visit” – provider also responsible for general supervision
    3.  Relates to SDOH that interfere with provider’s ability to diagnose and treat an identified medical condition
    4.  Claims may only be submitted by one billing provider for a given patient
    5.  Providers encouraged to partner with CBOs, but CBOs cannot bill directly

    Community Health Integration Services

    Medicare Billing Implementation Resources

    Click on the image above.

    Click on the image above .