Chronic Care Management supports patients in managing their chronic conditions, preventing future illness, slowing disease progression, and avoiding exacerbation.
A CCM program typically includes a variety of services proven to support chronic disease management, including:
- Patient-centric care planning
- Personalized goal setting
- Guided clinical or health risk assessments
- Monthly touchpoints via phone or telehealth
- Ongoing medical supervision and intervention
- Patient education about medical conditions, treatments, self-management
CCM facilitates effective management of chronic conditions—such as diabetes, hypertension, heart disease, and cancer—through personalized care planning, routine monitoring, and enhanced patient engagement.
This program is available to eligible Medicare beneficiaries, and reimburses providers for delivering direct or supervised remote care.
CCM Medicare patient qualifications
Medicare has three overarching eligibility requirements for the CCM program. The patient must:
- Be a Medicare fee-for-service or dual-eligible (Medicare and Medicaid) beneficiary
- Have two or more chronic conditions that are expected to last at least 12 months or until death
- Be at significant risk of death, acute exacerbation, decompensation, or functional decline due to these chronic conditions
Beyond these patient qualifications, providers must meet several requirements to support patient eligibility and enroll them in the CCM program.
Three steps to enroll patients in CCM
The initiating visit: New patients or those not seen in 12 months must have an initiating visit, during which their provider will inform the patient of their eligibility for the program and the benefits of enrolling.
Note that the initiating visit can happen during a comprehensive face-to-face evaluation and management (E/M) appointment or an Annual Wellness Visit (AWV). However, if the practitioner does not discuss CCM during an E/M visit, AWV or IPPE, that visit cannot be considered the initiating visit.
Informing the patient: During the initiating visit, the patient’s practitioner is required to notify the patient about crucial points related to the CCM program, including:
- What CCM services may entail
- The patient’s cost-sharing responsibilities
- Only one practitioner can provide and bill CCM services during a calendar month
- The patient can stop CCM services at any time, effective at the end of the calendar month
Related to cost, Medicare Part B covers the CCM service; however, beneficiaries may be responsible for cost-sharing, which could include a 20% coinsurance, copayment, or deductible. Medigap policies may help pay this cost.
Obtaining consent: Before joining the program or being billed for CCM services, the patient must give verbal or written consent, documented in their medical record.
Identify eligible patients for Chronic Care Management
Based on Medicare’s patient eligibility requirements, providers can use clinical and utilization details to identify a cohort that could benefit most from CCM services.
The Centers for Medicare & Medicaid Services (CMS) suggests criteria, including:
- Diagnosed chronic illnesses
- Prescribed medications
- Repeat admissions
- Emergency department visits
The American Academy of Family Physicians (AAFP) suggests several approaches that practices can use to identify the most appropriate patients that qualify for CCM services.
- Use the AAFP Risk-stratified Care Management Rubric to identify Medicare Part B patients with two or more chronic conditions expected to last at least 12 months or until death
- Prioritize patients with the highest risk of hospitalization
- Consider those patients who most often call the practice with medical questions or challenges managing their symptoms
- Filter patients who see the most specialists or have limited social or nearby family support
- Identify dually eligible patients for traditional Medicare and Medicaid but who are not managed by Medicaid
Key to identifying and triaging patients for Chronic Care Management is:
- Technology to support data analysis
- Documentation of CCM enrollment requirements
- Streamlined onboarding processes
ThoroughCare helps manage multiple conditions
Providers can manage care management programs effectively with ThoroughCare. As a comprehensive software platform, ThoroughCare streamlines care management across all program types by automatically accounting for Medicare’s rules and requirements while documenting service records.
Our end-to-end workflow simplifies program oversight, service delivery, and billing for Chronic Care Management. It provides a structured approach and evidence-based tools while enabling flexibility to meet individual patient needs.
Key questions answered
Which patients qualify for Chronic Care Management?
Original Medicare beneficiaries qualify for CCM services. They must have two or more chronic conditions. They are expected to last at least 12 months or until the patient’s death or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.
What are the next steps once a patient is identified as eligible for CCM?
The provider overseeing their care would need to meet requirements related to an initiating visit. This is where the patient is informed about cost-sharing responsibilities, their right to leave the program at any time, and that only one physician may bill for CCM services each month. The patient must give written or verbal consent, documented in the medical record.
How should providers identify eligible patients for Chronic Care Management?
Providers can use existing data from their electronic medical records to risk stratify their patient roster. They can use this data to identify a cohort that could qualify for and benefit from CCM services. Criteria to consider when identifying potential CCM patients include the number of chronic illnesses, prescribed medications, and repeat hospital admissions or emergency visits. Other factors could also merit CCM value, such as the number of specialists and lack of community or at-home support.