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You’ve heard correctly! While Medicare billing has not traditionally accounted for a large portion of CBO revenue, and few CBOs have had mechanisms in place to tap into this payment stream, that is changing rapidly as new Medicare codes and a proliferation of value-based payment reforms are incentivizing the kinds of preventative and community-support services CBOs provide. These new policy developments have opened up opportunities for CBOs to more fully integrate with the health care sector, and get paid in the process. Please see below for some high-level overview issues related to CBOs and Medicare

  • –Most of the current CBO Medicare reimbursement opportunities are available under Medicare Part B, which covers physician services, office visits, screenings, therapies, preventative care, and other outpatient services. Learn more about Medicare Part B HERE
  • –A Medicare Provider number is the key to being able to bill for services. A CBO can either go through the process to obtain its own Medicare Provider number to bill directly for some services, or can partner with an existing provider with a Medicare number to receive reimbursement. Different benefits have different rules for who exactly can bill Medicare directly. Learn more about how CBOs can obtain a Medicare Provider number HERE
  • –Currently, most of the Medicare billing for CBOs is centered around self-management and health and wellness promotion programs, as well as care management services. There are a number of Medicare Part B benefits that can be offered to obtain reimbursement for Chronic Disease Self-Management Education (CDSME) programs by billing Medicare directly. However, it is important to note that for the Chronic Care Management (CCM) and Complex Chronic Care Management (Complex CCM) services described below, a CBO CANNOT bill Medicare directly. They MUST partner with a physician or an eligible non-physician practitioner who can submit bills to Medicare for reimbursement.
  • –Below are the benefits most commonly furnished by CBOs, along with their corresponding billing codes (*note* “CPT” codes stand for “Current Procedural Terminology” codes. CPT codes are a set of medical billing codes that are developed and owned by the American Medical Association).

Please click on the benefit names for more detailed information about each:

Diabetes Self-Management Training (DSMT):

CPT Billing Codes:

-G0108 (for DSMT provided to an individual)

-G0109 (for DSMT provided in a group setting)

Medical Nutrition Therapy (MNT)

CPT Billing Codes:

-97802 (for MNT provided to an individual)

-97804 (for MNT provided to an individual)

Health Behavior and Assessment Intervention (HBAI)

CPT Billing Codes:

-96150: (for the initial Health and Behavior assessment)

-96152: (for an individual intervention)

-96153: (for a Health and Behavior intervention service provided in a group setting)

Chronic Care Management (CCM)

CPT Billing Codes:

– 99490 (for 20 min of clinical staff time)

Complex Chronic Care Management (Complex CCM)

CPT Billing Codes:

-99487 (for 60 min of clinical staff time)

-99489 (for each additional 30 min of clinical staff time)

Health care systems and their payers are moving rapidly away from pay-for-service and toward pay-for-value. As part of this evolution, there is an increasing level of recognition that addressing social determinants of health (e.g. physical environments, social support networks, etc.) should be an integral part of a patient’s health care. As health plans and systems look for ways to reduce costs and improve quality, CBOs must partner with them to expand access to evidence-based health promotion programs, nutritious food, transportation, and other services for older adults and people with disabilities. These powerful motivators are driving change throughout the health care system and CBOs need to understand and embrace a new, integrated role as part of the public-private shift towards measuring and rewarding value.

The short answer is, maybe. If your state has adopted or will soon adopt managed long term services and supports (MLTSS), reach out to the managed care organizations (MCOs) bidding on or contracting with the state to manage its MLTSS program and discuss opportunities to work together. Do your homework and to be certain you understand what LTSS the state is including and, if available, what the state’s rate is for that service(s).

Be prepared to discuss your CBO’s value proposition and why the MCO should contract with you to provide the covered service(s) to its members. Be creative! States typically apply performance and patient outcome measures that focus on achieving better care, better health and lower costs. Be certain you understand these incentives and how your CBO’s proposed services can help that MCO improve their clients’ health, increase satisfaction, and lower health care costs.

One of the best ways to know if your CBO is read is to conduct a thorough and objective examination of the CBO’s existing service offerings, internal capacity, structure, financing, and general business acumen. The Business Institute is developing a Readiness Assessment to be launched in 2017. Consultants from the n4a Consulting Program are also available to help you assess the organization’s readiness (a fee-based program). For more information on the n4a consulting program, click HERE


Focus on your CBO’s value proposition.  Determine what the MCO needs and identify the service offerings your CBO can provide to address those needs. And remember that this is marketing and you are entering a competitive space. Packaging, pricing and people are three critical ingredients.  Focus on these to ensure that you are offering and effectively communicating a serious value proposition that addresses a key need for the MCO.

The answer to this questions depends somewhat on the environment in your community and state. For example, if your state is considering a move to managed long term services and supports (MLTSS), you will want to talk with the state agency responsible for the bid process. You will be interested in learning which MCOs are considering making a bid in your state or geographic region. In many instances, the MCOs will actual contact you, so be prepared for that call! For more information and tools on talking with MCOs and other payers, visit our “Define Your Value” resources page.


The best place to start is with an assessment of your current cost structure for the service(s) under your existing program(s). A partial list of additional considerations may include: liability insurance, performance standards (response times, etc.), metrics (percent reduction in readmit rates), the impact of variability in volume and scale, payment incentives (or penalties), and any additional provision that you may consider in your contract negotiations with the MCO that may shift non-fixed costs to your agency (capitated rates, etc.). For more information on pricing, see our pricing-specific resources on our “Manage Finances” page.

A Medicare Provider Number, officially a National Provider Identifier (NPI), is provided by the Centers for Medicare and Medicaid Services (CMS) to registered providers that allows that individual or, in some cases an organization, to bill Medicare or your state Medicaid program for covered services. First, your CBO will want to determine if it offers services that traditional Medicare or your state’s Medicaid program may pay for. If so, your CBO may wish to secure (directly or through an affiliate organization) a NPI.  To learn more about potential CBO-Medicare billable services, click HERE. For instructions on how to obtain a Medicare Provider Number, click HERE.

Recognition of the value patients receive through integrated care continues to grow and part of that recognition is an understanding of the impact social determinants have on an individuals overall health and well-being. The purpose of the Business Institute is to help CBOs hone their business acumen skills to partner with health and managed care organizations and value in these new integrated care systems.  By doing so, CBOs bring value to their communities, value to their partner organizations and other funders, and value to the individuals and caregivers we all serve. Change is inevitable with each new Administration and, regardless of any changes that may be proposed, where CBOs demonstrate their value, this work will continue and will be an essential part of future integrated care models, to the well-being of older adults and persons with disabilities across the nation.

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