What Is Medicare Chronic Care Management?

Managing your health and life with one chronic condition is hard enough. Grappling with two or more can be overwhelming. If you’re eligible for Medicare and have multiple, serious chronic conditions, a Medicare Chronic Care Management plan may be the game changer you’re looking for.

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions.

Medicare Chronic Care Management (CCM) is a comprehensive care plan you sign up for through a Medicare-approved healthcare provider. These providers include doctors, nurse practitioners, and physician assistants.

CCMs streamline and organize your care across multiple disciplines and professionals. If you have a CCM, the prescriptions, appointments, and therapies you need to manage all your healthcare needs will be overseen by one healthcare professional committed to your care and understands your goals and needs.

CCMs provide 24/7, round-the-clock healthcare and support, should you need it. They also take care of services you may need within your community, such as support groups and transportation to and from medical appointments.

What is a CCM care plan?

CCM care plans provide chronic care management services that are personally overseen by a doctor or other qualified healthcare professional. CCM care plans eliminate the need for you to juggle or worry about the varying treatments needed for your conditions.

The plan will help support disease control and health management goals, including physical, mental, cognitive, psychosocial, functional, and environmental factors. Beneficiaries may also receive a list of suggested resources and community services. Additionally, plans encourage members to keep track of referrals, community support, and educational information. Care plans can also help caregivers who are furnishing care.

The medical professional in charge of your plan will integrate your healthcare protocols by keeping track of appointments, treatments, and medications. They will make sure the prescriptions you receive for each diagnosis can be safely taken together. It is their responsibility to establish, implement and monitor your plan. It is also their responsibility to revise it as needed, based on changes in your healthcare needs or prognosis.

A CCM care plan is an individualized roadmap to the care you need. The elements a plan contains may vary based on the level of support you require, including hospital stays, at any given time.

Some services you may receive once you sign up for a CCM include:

• 24/7 access to a healthcare professional via phone or electronically
• At least 30 minutes of face-to-face time with a healthcare professional monthly
• A comprehensive electronic record of your chronic conditions and treatments, such as medications and physical therapy
• A written plan for your care that includes goals and management
• Contact information for all your healthcare providers
• A list of community services you need or use

Medicare Part B covers 80% of the cost of Chronic Care Management, provided it is administered by a Medicare-approved healthcare professional.

Medicare Advantage (Part C) plans also cover the cost of CCMs. Your out-of-pocket costs may be different if you have a Part C plan. Your Part C plan will cover at least as much or more than Original Medicare does.

To get coverage, you must meet specific requirements:

• You must already be a Medicare beneficiary or be eligible for Medicare.
• You must have two or more serious chronic conditions that will last for at least one year, or until your death.
• According to Medicare, these conditions must put you at significant risk of death, acute exacerbation/decompensation, or functional decline.

What conditions qualify for chronic care management?

Many severe conditions make you eligible for chronic care management. You must have two or more conditions that will last for one year or longer.

These conditions include, but are not limited to:

• Cancer
• HIV/AIDS
• Chronic obstructive pulmonary disease (COPD)
• Diabetes
• Arthritis
• Dementia
• Alzheimer’s disease
• Heart disease
• High blood pressure
• Depression
• Asthma
• Autism
• Lupus
• Multiple sclerosis

If your healthcare provider takes Medicare assignment, Medicare will pay 80% of the Medicare-approved cost for all the services and supplies you get through your plan. These include:

• Doctor’s visits
• X-rays
• Durable medical equipment, such as a wheelchair or cane
• Physical and occupational therapy
• Smoking cessation programs
• Mental health appointments
• Preventive care measures, such as vaccines

You are responsible for the other 20% of the cost. Based on your insurance, you may also be responsible for copays, deductibles, and Medicare Part B monthly premiums. If you have Medigap supplemental insurance, these out-of-pocket costs may be covered by your plan.

Talk to your current medical provider about getting a CCM. If they don’t offer this service, they may recommend you to a physician who does.

Your first step will be a face-to-face appointment with a CCM provider. They will evaluate you for a CCM plan and help you to decide if this type of plan will be beneficial for you. At this meeting, you or your representative can ask questions about the plan and how it will be administered and maintained.

If you decide that a CCM plan is a good fit, you will sign a form indicating that you wish to avail yourself of CCM services.

Your CCM manager will coordinate payment of the services you need with Medicare.

Your chronic care manager’s goal is to make sure you receive optimum medical support for every chronic condition you are diagnosed with.

Your chronic care manager will provide personalized insight and support to you. They will get to know you and will understand your healthcare needs and goals. They or their representative will be available to you for urgent care needs 24 hours a day, seven days a week.

A Chronic Care Manager is responsible for a variety of functions, which may include:

• Generating and maintaining a comprehensive, electronic care plan
• Recording new health information and keeping the plan updated
• Coordinating the care you need across multiple providers
• Updating your providers with any changes in your health or healthcare needs
• Overseeing your medications and therapies
• Maintaining a record of medication allergies and other pertinent allergies you may have
• Determining that the dietary recommendations you are given for your conditions don’t contradict each other
• Keeping track of your appointments
• Arranging your medical transportation needs
• Revising your treatment plan as needed
• Educating you about your health and medical treatments