Chronic Care Management

Structured, ongoing coordination and non-face-to-face support for patients with multiple chronic conditions, including care planning, medication management, and coordination with specialists and pharmacies — much of the work happens between office visits.

Patients with two or more chronic conditions expected to last at least 12 months (or until death) that place them at significant risk of exacerbation, functional decline, or death — for example, diabetes plus hypertension, or heart disease. This is commonly offered under Medicare guidelines.

Comprehensive care plan development and review, regular check-ins by phone or portal, medication reconciliation, coordination with specialists and pharmacies, 24/7 access for urgent needs related to your conditions, and preventive service reminders and education.

Yes — enrollment requires your consent and, in many programs, an initiating visit. Time thresholds also apply for billing, such as a minimum number of minutes per month.

No — CCM supports your ongoing chronic condition management between visits, but it is not a substitute for acute care.

Medicare Part B commonly covers CCM, with a possible 20% coinsurance after your deductible; coverage varies with other insurers. Self-pay is $125 for new patients and $100 for established patients.