You have been managing high blood pressure for a few years now. The medication helps, but your numbers still are not quite where your doctor wants them. At every visit you leave with the same advice: eat better, reduce stress, come back in three months. Nobody has asked whether getting to those appointments is a problem, or whether the food you are supposed to eat is actually affordable in your neighborhood, or whether managing this condition alone is part of what is making the rest harder.
That gap between what a doctor can do in an appointment and everything else that affects your health has existed in medicine for a long time. In 2024, Medicare created a benefit designed specifically to address it.
It is called Community Health Integration, or CHI. Most patients have not heard of it. Most doctors are still learning about it. And that is exactly why it is worth knowing, along with several other Medicare benefits most people never use.
What Is Community Health Integration (CHI)?
Community Health Integration, or CHI, is a Medicare benefit that became available on January 1, 2024, through the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs the Medicare program. The benefit exists because CMS recognized something that clinical medicine has been slow to acknowledge: a significant part of what determines whether you actually stay healthy has nothing to do with your prescriptions or your lab results. It has to do with whether you can get to your appointments, whether you can afford your medications, whether you are eating in ways that support your health, and whether you have the knowledge to navigate a healthcare system that is not always designed to be easy.
These factors, transportation, food access, housing, financial stress, social isolation, difficulty understanding your coverage, are sometimes called “social determinants of health.” That is a clinical term for a straightforward idea: where and how you live affects how healthy you are. CHI is Medicare’s formal commitment to paying for help with those things.
What Are Community Health Integration Services?
Community Health Integration services cover three core areas. The first is person-centered assessment and planning: figuring out, specifically, what social and environmental factors are affecting your ability to manage your health. The second is care coordination and navigation: connecting you to the resources that can address those factors. The third is patient education and self-advocacy: understanding your rights, your coverage, and how to ask for what you need.
In practical terms, that might mean a community health worker, someone whose specific job is to help you access the services and resources that affect your health, connecting you with food assistance programs in your area. It might mean arranging transportation to a specialist or helping you get to a lab appointment. It might mean helping you understand what your Medicare coverage actually includes, so you are not leaving benefits on the table the way most patients do.
The specific barriers CHI is designed to address include transportation to appointments, food access and nutrition, housing stability, financial insecurity, social isolation, and general difficulty understanding and navigating the health system.
Is Community Health Integration Available Through Medicare Advantage?
CHI is a traditional Medicare Part A and Part B benefit. Medicare Advantage plans are administered separately by private insurers, and CHI is not automatically included the same way. That said, some Medicare Advantage plans offer their own similar care coordination or social support programs under different names, so it is worth calling your specific plan to ask whether something comparable to CHI Medicare Advantage coverage exists for you. If you are enrolled in traditional Medicare, CHI is available directly through Medicare Part B without needing a separate plan add-on.
How Is Community Health Integration Different from Chronic Care Management?
This is the question most patients ask once they have heard about both programs.
Chronic Care Management, or CCM, is a Medicare benefit for people with two or more ongoing conditions, diabetes, high blood pressure, heart disease, COPD, depression, and others. A care coordinator works with you every month: tracking your medications, making sure your doctors are communicating with each other, and helping you manage your care between appointments. CCM addresses the clinical and medical side of your conditions.
CHI covers the social and environmental side. You might have solid CCM support and still be struggling because you do not have reliable transportation to the lab, or because eating well on a fixed income in your neighborhood is genuinely difficult, or because you are managing everything alone and it is wearing you down.
The two programs cover different layers of the same situation, and they can both be active in the same month. If you qualify for both, you do not have to choose.
Who Qualifies for Community Health Integration Services Through Medicare?
CHI is available to patients enrolled in traditional Medicare, Medicare Part A and Part B, who have social or environmental factors affecting their health. Medicare Advantage plans are separate; some have their own similar programs, so it is worth asking your plan directly if that applies to you.
To get CHI services started, a physician, nurse practitioner, physician assistant, or other billing practitioner needs to identify the social factors affecting your health during a visit. This can be an office visit, a telehealth appointment, or your annual Medicare wellness visit. If your provider documents those needs during that visit, CHI services can begin.
The services can be provided in person or by phone or video, which matters for patients who have mobility issues, live somewhere getting to an office is difficult, or simply prefer to handle their care from home.
Does Community Health Integration Cost Anything?
CHI is billed under Medicare Part B, so standard Medicare cost-sharing applies. What you pay depends on your specific coverage. If you have a Medigap supplemental policy, it may cover the cost-sharing portion. If you are enrolled in a Medicare Savings Program, your costs may be reduced or eliminated. If you are not sure what applies to your situation, that is exactly the kind of question a CHI care coordinator can help you work through.
Why Is Community Health Integration So Underused?
Because CHI is new, and because the system has never been particularly good at telling patients what they qualify for.
CHI has only been available since January 2024. Many providers are still learning that it exists. Many have not yet integrated it into their practice. And patients are almost never told about it proactively.
That pattern is not new. Chronic Care Management has been a Medicare benefit since 2015, and the majority of patients who qualify for it still have not used it. CHI is in the same position now, except it is newer and even less widely known. That is starting to change, but slowly. The gap between eligibility and access remains especially wide for patients managing multiple conditions without much support.
Knowing this benefit exists is the first step to using it.
How POD Health Can Support Your Medicare Community Health Integration Benefits
POD Health connects Medicare patients across all five boroughs of New York City, including Staten Island, Brooklyn, Queens, the Bronx, and Manhattan, as well as Westchester County, Florida, and Colorado. Our dedicated care coordinator supports patients who may qualify for Community Health Integration (CHI). If you are managing a chronic condition and dealing with any of the barriers CHI is designed to address, transportation, food access, difficulty navigating your coverage, or simply feeling like you are managing too much alone, the POD Health team can help you understand your options. Contact us today to find out whether you qualify for CHI through Medicare at no cost to you.
