Help with social needs: what Medicare covers and who qualifies

Short answer

Community resource navigation is a Medicare service that pays for a trained community health worker (or similar auxiliary personnel) to help patients address the social and behavioral factors making their medical care harder to follow. Ask the treating physician to initiate community resource navigation if your loved one is struggling with housing, food, transportation, utilities, personal safety, or another factor getting in the way of their treatment.

What community resource navigation actually addresses

The core CMS definition, from the CMS Health-Related Social Needs FAQ, is that community resource navigation services address unmet social determinant of health (SDOH) needs that affect the diagnosis and treatment of the patient’s medical problems.

The traditional SDOH categories are:

• Housing insecurity — the patient is at risk of losing their home, is living in unsafe conditions, or is unhoused.
• Food insecurity — the patient does not have reliable access to affordable nutritious food.
• Transportation — the patient cannot reliably get to medical appointments.
• Utility difficulties — inability to pay for electricity, heat, or water is putting the patient at risk (spoiled medications requiring refrigeration, home too cold in winter for a patient with heart failure).
• Personal safety — the patient is in a domestic-violence situation or an unsafe neighborhood affecting their willingness or ability to leave home.
• Other — any material need the treating clinician documents as affecting diagnosis or treatment.

In 2026, CMS broadened the scope. The icd10monitor / MedLearn 2026 expansion summary states that community resource navigation services may now address ‘any unmet upstream driver’ affecting patient behaviors (smoking, nutrition, physical activity, substance use) beyond Social Determinants of Health. This 2026 expansion means community resource navigation now reaches behavioral drivers that were previously outside its scope.

Who qualifies

The patient does not need a specific diagnosis. They need:

1. A qualifying medical condition or presenting complaint that the treating clinician has identified and is actively managing.
2. An unmet upstream driver — an SDOH or behavioral factor — that the clinician has documented as affecting diagnosis or treatment.
3. An initiating visit — an evaluation-and-management visit where the clinician identifies the unmet driver and initiates community resource navigation services.

The 2026 community resource navigation expansion also broadened what counts as an initiating visit. Behavioral-health visits — psychiatric diagnostic evaluation and health-behavior assessment — now qualify to start community resource navigation services. Before 2026, primary-care and specialty-care E/M visits were the main initiating visits.

Who delivers community resource navigation

Community resource navigation is delivered by auxiliary personnel — trained non-physician staff working under the direction of the billing practitioner. The Rural Health Information Hub describes these services as being performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner.

The categories of auxiliary personnel who can deliver community resource navigation include:

• Community health workers (CHWs) — the most common category. Many CHWs come from the same community as the patients they serve.
• Registered nurses (RNs) and licensed practical nurses (LPNs) — CMS’s 2026 update explicitly clarified that the codes do not limit the types of other health care professionals, such as registered nurses and social workers, that can perform community resource navigation services.
• Social workers (LCSW, LMSW, LSW)
• Marriage and family therapists (MFTs) — added as eligible providers in the CY 2026 PFS.
• Mental health counselors (MHCs) — added as eligible providers in the CY 2026 PFS.

Auxiliary personnel must meet the state’s certification or licensure requirements. Where a state has no applicable requirement, CMS requires that the person be “trained or certified in the competencies of: Patient and family communication…Service coordination and system navigation”.

The billing practitioner supervises. They do not need to be physically present while the community resource navigation activities happen. A single treating physician can supervise multiple CHWs and social workers, which is what makes community resource navigation scalable within a primary-care practice or community health center.

What community resource navigation activities look like month-to-month

The four categories of activity include:

1. Person-centered assessment. The CHW meets with the patient (and often a family caregiver), documents the unmet driver, and builds a written plan tied to the medical condition.
2. Care coordination. The CHW makes phone calls the patient cannot make: contacting the housing assistance agency, arranging for medically-tailored meals through a partner organization, coordinating transportation to specialty appointments.
3. Health education and behavioral support. For the 2026-expanded behavioral scope, this is where nutrition education, physical-activity guidance, smoking cessation referrals, and substance-use resources come in.
4. Self-advocacy skill-building. Over time, the CHW teaches the patient how to navigate the systems they will keep encountering after community resource navigation ends.

CMS does not require all four every month. The rule is that “those service elements that are reasonable and necessary for the individual patient” are documented and delivered.

How to ask for community resource navigation

Community resource navigation is not something patients enroll in independently. Concretely:

1. Name the unmet driver at a medical appointment. Housing, food, transportation, utilities, safety — or, since 2026, a behavioral factor like nutrition, physical activity, smoking, or substance use.
2. Ask the treating clinician to document the driver and initiate community resource navigation. CMS requires the clinician to record the qualifying medical condition and the unmet driver as part of the initiating visit.
3. Ask about the practice’s CHW capacity. Many practices work with a contracted CHW organization rather than employ CHWs directly. Either arrangement works — CMS reimburses the practice, which then compensates the CHW.
4. Consent to the service. CMS requires patient consent for community resource navigation. Standard Part B cost-sharing applies (20 percent coinsurance after the annual Part B deductible of $283 in 2026).
5. Expect first contact within days. The CHW should reach out within the first week of the initiating visit. If two weeks pass with no contact, follow up with the practice.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) may bill community resource navigation under adapted rules. If your loved one gets primary care at an FQHC or RHC, the practice’s billing team is the right point of contact.

What community resource navigation does not cover

• Direct payment for housing, food, or transportation. Community resource navigation pays for navigation services — connecting the patient to community resources — not for the underlying goods and services themselves.
• Case management for the whole family. Community resource navigation is patient-focused. The caregiver benefits from the CHW’s work but the billing is for the patient’s navigation.
• Coverage decisions. Community resource navigation helps a patient access coverage and community resources, not adjudicate them.

When a patient advocate adds specific value alongside community resource navigation

A CHW providing these navigation services is embedded in a physician practice and bills incident-to that practice. An independent patient advocate — Baba’s model — operates outside the practice. Three situations where the two complement each other:

1. When multiple providers are involved. A CHW at primary care cannot easily coordinate the specialty, home-health, and social-services arms of a complex case. An independent advocate operates across providers.
2. When the family needs the coordinator. Community resource navigation pays for services delivered to the patient. Families often need someone holding the whole picture, especially at moments of transition (hospital discharge, new diagnosis, moving between care settings).
3. When community resource navigation is not available. Not every primary care practice has CHW capacity yet. An independent advocate can deliver similar navigation without the practice-level barriers.

Baba Care advocates work alongside community resource navigation when it is available and instead of it when it is not. Contact us to discuss the specific fit for your family’s situation.

Frequently asked questions

Is community resource navigation a Medicare pilot or a permanent benefit? A permanent benefit. CMS established community resource navigation in the CY 2024 Medicare Physician Fee Schedule final rule (88 FR 78818). It is billable under Original Medicare from January 1, 2024 onward and was expanded in the CY 2026 rule (90 FR 49480).

Does my loved one pay anything for community resource navigation? Standard Part B cost-sharing: after the annual Part B deductible ($283 in 2026), Medicare covers 80 percent and the patient pays 20 percent coinsurance. A Medigap or Medicare Advantage plan typically covers the coinsurance.

Does Medicare Advantage cover community resource navigation? Medicare Advantage plans must cover everything Original Medicare covers, including community resource navigation. Some MA plans deliver similar services under a different name; check the specific plan.

What changed with community resource navigation in 2026? Three things. First, MFTs and mental health counselors were added as eligible auxiliary personnel. Second, behavioral-health visits (psychiatric diagnostic evaluation, health-behavior assessment codes) now qualify as initiating visits. Third, the service scope was broadened from formal SDOH to any unmet upstream driver of the patient’s medical situation — including nutrition, physical activity, smoking, and substance use.

Where does community resource navigation apply outside primary care? Community resource navigation can be billed by any Medicare-enrolled practitioner who conducts an eligible initiating visit and identifies an unmet driver. That includes specialty practices, FQHCs, and RHCs. The service is not limited to primary care.

About Baba Care. Baba Care is a patient advocacy service supporting families navigating Medicare and complex care decisions. We are not affiliated with the Centers for Medicare & Medicaid Services or any Medicare provider.

Medical / financial disclaimer. This article is educational and does not constitute medical, financial, or legal advice. For personal circumstances, consult a licensed clinician, financial adviser, or attorney.

Additional source references

• CMS · CY 2024 Medicare Physician Fee Schedule Final Rule · 88 FR 78818
• CMS · CY 2026 Medicare Physician Fee Schedule Final Rule · 90 FR 49480