CMS 2026 Updates Expand Community Health Integration Provider Eligibility and Initiating Visits

The Centers for Medicare & Medicaid Services (CMS) finalized notable updates in the CY 2026 Physician Fee Schedule (PFS) regarding Community Health Integration (CHI) services. These changes build upon prior 2024 and 2025 regulations that initially enabled reimbursement for community health workers providing CHI services under physician supervision. The CY 2026 rule expands the scope of authorized CHI service providers to include Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), recognizing their roles in social determinants of health (SDoH) assessments, behavioral interventions, and care coordination. Previously, CHI services could be initiated primarily through Evaluation and Management (E&M) visits and select preventive services. The new regulation broadens qualifying initiating visits to include behavioral health visits such as psychiatric diagnostic evaluations and health behavior assessment and intervention codes (HBAI). This adjustment reflects an effort to better integrate behavioral health practitioners into CHI service pathways and address psychosocial barriers to care. The definition of CHI services continues to focus on addressing unmet upstream drivers impacting patient health behaviors and outcomes, including factors like substance use and nutrition, while reinforcing requirements for person-centered assessment, care planning, and facilitation of community and social supports. CMS’s refinements clarify which healthcare professionals meet auxiliary personnel qualifications and emphasize training aligned with CHI service expectations. The regulatory shift aims to improve patient access and reduce bottlenecks in ambulatory and behavioral healthcare, particularly in underserved and rural areas. These updates operate within the broader framework of CMS seeking to enhance coordination between medical and behavioral health domains and align reimbursement mechanisms with integrated care delivery models. Ongoing challenges in accurate coding, compliance, and denial management remain relevant as providers and payers adjust to evolving policies and audit scrutiny. Comprehensive understanding of these changes is vital for healthcare organizations aiming to optimize compliance, coding accuracy, and revenue cycle management under the new CMS guidance.