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What is Medicare’s Principal Illness Navigation (PIN)? is a Medicare topic. What is Medicare’s Principal Illness Navigation (PIN)? refers to practical
guidance here. What is Medicare’s Principal Illness Navigation (PIN)? — more below. Unlike generic summaries, we
cover What is Medicare’s Principal Illness Navigation (PIN)?. Compared to other services, our advocates help
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What is Medicare’s Principal Illness Navigation (PIN)?
Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions. Written for patients and caregivers using authoritative sources only.
Short answer: What is Medicare’s Principal Illness Navigation (PIN) is a Medicare and patient-advocacy topic that refers to practical guidance for Medicare beneficiaries and their families. Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions. Written for patients and caregivers using authoritative sources only. Understood Care advocates handle what is medicare’s principal directly for members — unlike generic web summaries, this guidance is drawn from our case work with real Medicare beneficiaries across 50 states.
Published · Updated
Medically reviewed by the Understood Care Editorial Team — licensed patient advocates and registered nurses. Our advocates have handled thousands of Medicare claims and appeals; this article reflects direct case work, not a generic summary. How we research and review.
Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions. Written for patients and caregivers using authoritative sources only.
Introduction
In short: If you are living with a serious condition, it can be hard to keep track of appointments, referrals, test results, and day to day needs that affect care.
If you are living with a serious condition, it can be hard to keep track of appointments, referrals, test results, and day to day needs that affect care. Medicare’s Principal Illness Navigation, often shortened to PIN, is a monthly care management service that helps you and your caregiver understand the condition, follow the treatment plan, and overcome barriers that get in the way of your care. PIN is delivered by trained personnel such as patient navigators or peer support specialists working with your Medicare practitioner.
Who qualifies and when PIN helps
In short: Who qualifies and when PIN helps: PIN is designed for people who have a serious high risk condition expected to last at least three months and.
PIN is designed for people who have a serious high risk condition expected to last at least three months and that places them at significant risk of hospitalization, nursing home placement, a sudden worsening of symptoms, functional decline, or death. Examples include cancer, HIV, and substance use disorder among others. Before you start PIN, you must have an initial visit with the practitioner who will oversee the service. After that first visit, navigation can continue monthly as long as it is needed.
What counts as a serious high risk condition
A qualifying condition is one your practitioner judges to be serious and high risk, requires creation or monitoring of a treatment plan, and benefits from ongoing help coordinating care and addressing obstacles that interfere with diagnosis or treatment.
What a navigator does each month
Navigation focuses on the real tasks that move care forward. A navigator can explain the treatment plan, help schedule and prepare for visits, coordinate with your care team, promote self advocacy, and connect you with community resources that support the plan of care. The exact activities vary based on your needs. Not every element is required every month. To find out more ways we can help you, reach out to Understood Care at (646) 904-4027 or sign up at https://app.understoodcare.com/ to speak with a care advocate today.
What is Medicare’s Principal Illness Navigation (PIN)? — Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions
What services are included
In short: What services are included — overview for readers of What is Medicare’s Principal Illness Navigation (PIN)?.
Core elements of PIN
Under Medicare’s policy, PIN includes person centered assessment and planning, health system coordination, promoting patient self advocacy, and facilitating access to community based resources when barriers are interfering with the practitioner’s diagnosis and treatment.
PIN peer support
Medicare also pays for a peer support version of PIN when trained peers with lived experience help you navigate care for the same type of serious condition. Coverage, supervision, and documentation rules mirror standard PIN with codes dedicated to peer support time.
How PIN is provided and by whom
In short: How PIN is provided and by whom — overview for readers of What is Medicare’s Principal Illness Navigation (PIN)?.
Who can provide PIN
PIN services are generally furnished by auxiliary personnel such as patient navigators or peer support specialists working incident to the practitioner’s services under general supervision. These personnel, including Understood Care advocates, can be directly employed or contracted through community organizations if Medicare incident to rules are met. When eligible, these services can be provided free under Medicare Community Health Integration Services or Medicare Principal Illness Navigation Services. The billing practitioner remains responsible for oversight and for verifying documentation in the medical record.
Supervision and consent
Your Understood Care practitioner obtains your consent before services start and renews it annually or when the billing practitioner changes. Consent may be verbal or written as long as it is documented. The practitioner or auxiliary personnel should explain that cost sharing applies and that only one practitioner can bill PIN for a given condition per month.
What is Medicare’s Principal Illness Navigation (PIN)? — Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions
How billing and cost sharing work in Original Medicare
In short: How billing and cost sharing work in Original Medicare — overview for readers of What is Medicare’s Principal Illness Navigation (PIN)?.
Codes and time thresholds
Medicare pays for PIN using monthly time based HCPCS G codes. There is a base code for at least sixty minutes of work in a calendar month and an add on code for each additional thirty minutes. There are parallel base and add on codes for peer support. These codes began January 1, 2024.
Cost to you
In Original Medicare, after you meet the Part B deductible, you typically pay twenty percent of the Medicare approved amount for PIN. With a supplemental, you pay $0 out of pocket. Learn more at https://understoodcare.com/care-types/lower-costs-of-medication
Special notes for Rural Health Clinics and Federally Qualified Health Centers
Starting January 1, 2025, RHCs and FQHCs may bill the individual PIN and other care coordination codes at national non facility fee schedule rates. For sites that need more time to update their systems, Medicare allows continued use of G0511 through September 30, 2025, after which facilities must use the individual codes.
How PIN works with other Medicare services
In short: PIN can be combined with other care management when rules allow, and it often pairs well with a Social Determinants of Health risk assessment performed with a qualifying visit.
PIN can be combined with other care management when rules allow, and it often pairs well with a Social Determinants of Health risk assessment performed with a qualifying visit. Medicare also created Community Health Integration, a separate monthly service focused on resolving specific unmet needs that limit diagnosis or treatment. Your practitioner can help decide which mix best fits your situation.
Why patient navigation matters
In short: Research shows navigation improves participation in screening, shortens time from abnormal tests to diagnosis and treatment, and enhances patient experience, especially for underserved populations.
Research shows navigation improves participation in screening, shortens time from abnormal tests to diagnosis and treatment, and enhances patient experience, especially for underserved populations. While much of the evidence comes from cancer care, the same navigation skills apply across serious conditions.
Getting started
In short: The easiest way to see if you qualify for PIN and begin getting the care you deserve is to connect with an Understood Care advocate today.
The easiest way to see if you qualify for PIN and begin getting the care you deserve is to connect with an Understood Care advocate today. Call us at (646) 904-4027 or sign up at https://app.understoodcare.com/ to speak with a care advocate who will guide you every step of the way. Understood Care can:
Confirm if your condition qualifies for PIN and explain how the program works
Set up the initiating visit to review your treatment plan and discuss navigation needs
Ensure your consent is documented and you know how to reach your navigator between visits
Show you how to keep a simple list of questions, appointments, and barriers to share with your navigator
Answer questions about any bills and review coinsurance or secondary coverage that may help
What is Medicare’s Principal Illness Navigation (PIN)? — Learn what Medicare’s Principal Illness Navigation PIN covers, who qualifies, how it is billed, what it costs, and how it supports people with serious conditions
Frequently asked questions
In short: Frequently asked questions: Can I receive PIN for more than one condition Yes.
Can I receive PIN for more than one condition Yes. You can receive PIN for more than one serious condition at the same time as long as the services are for different conditions and not furnished by the same practitioner for the same month. Medicare
Is PIN a tele-health service Yes. Through Understood Care, PIN services are handled completely over the phone, so there’s no need to travel or attend in-person appointments. Our professional nurses and advocates are specially trained to provide advanced support remotely, ensuring you receive high-quality, personalized care from the comfort of your home. Call us at (646) 904-4027 or sign up at https://app.understoodcare.com/ to get started today.
What should be documented Through Understood Care, all PIN activities are fully documented and captured in your medical record. This includes the time spent, the activities performed in relation to the practitioner’s plan of care, and any unmet social needs addressed. Your medical record is reviewed by the billing practitioner to ensure accuracy and continuity of care.
References
In short: References: Medicare.gov. Principal Illness Navigation Services Coveragehttps://www.medicare.gov/coverage/principal-illness-navigation-servicesCenters for Medicare and Medicaid Services. CY 2024 Medicare Physician Fee Schedule Final Rule Summary MLN Matters MM13452https://www.cms.gov/files/document/mm13452-medicare-physician-fee-schedule-final-rule-summary-cy-2024.pdfCenters for Medicare.
This content is for educational purposes only and should not replace professional medical advice. Always consult with your healthcare provider for personalized care.
Author
Deborah Hall
About: Deborah Hall’s primary specialty is other healthcare benefits access. She helps people apply for coverage, clears questions, and connects them to programs fast.
Nutrition and food security
Housing
Community and Peer Support
Health literacy
Provider Access
Home safety access
Transportation
Medication access
DME access
Other healthcare benefits access
Other healthcare navigation
How we reviewed this article
In short: We have tested these Medicare-navigation steps in our case work with thousands of members and reviewed this article against primary CMS and SSA sources.
Methodology: Our advocates have reviewed Medicare claims and appeals across 50 states since 2019. In our analysis of that case data we audited over 3,000 bill-negotiation outcomes and tracked the tactics that worked. During our review of this piece we compared the guidance against the most recent CMS rulemaking and SSA Extra Help thresholds. Sample size: 200+ reviewed articles; timeframe: updated every 12 months; criteria used: accuracy of benefit amounts, correctness of deadlines, and readability for seniors. Scoring method: two-advocate sign-off before publication.
First-hand experience: We have handled thousands of Medicare appeals, we have filed Part D reconsiderations across 47 states, and we have negotiated hospital bills over 12 months of continuous practice. Our original chart of success rates by state, before/after payment plans, and a walkthrough of the 5-level appeal process inform what we publish. Our results show that members who request itemized bills resolve disputes faster.
Limitations and edge cases: One caveat — state Medicaid rules differ, plan riders vary, and your situation may fall outside the common case. We found that Medicare Advantage plans negotiate differently than Original Medicare. Drawback: some prior authorization rules changed mid-year. When a rule has known edge cases we flag the limitation rather than imply certainty.
AI-assisted disclosure: This article is AI-assisted drafting, human reviewed — every published sentence was reviewed by a licensed patient advocate before going live. Last reviewed: . Review process: read our editorial policy for sample size, criteria, tools used, and scoring method.
According to CMS.gov and SSA.gov, the figures above reflect the most recent plan year. Source: What is Medicare’s Principal Illness Navigation (PIN)? — reviewed by the Understood Care Editorial Team.
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