Chronic Care Management

Chronic Care Management (CCM) services include at least 20 minutes of clinical staff time directed by your physician or another qualified healthcare professional, per calendar month with the following required elements:

You must have multiple (two or more) chronic conditions expected to last at least 12 months, or until death
These chronic conditions place you at significant risk of death, acute exacerbation/decompensation or functional decline

If you elect to enroll in CCM services, you will have a comprehensive care plan established, implemented, revised as often as needed and monitored by your healthcare provider and our chronic care staff.

Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of taking care of the patient all of the time, not just at the point of care. Therefore, CCM services are typically provided outside of face-to-face patient visits and focus on.

A continuous relationship with a designated member of the CCM team
Support for chronic diseases to achieve health goals
24/7 patient access to care and health information
Preventative care
Patient and caregiver education and engagement
Timely sharing and use of health information
Medication reconciliation

Initiating Visit

Medicare requires initiation of CCM services to take place during a face-to-face visit with your healthcare provider (physician, certified nurse midwife, clinical nurse specialists, nurse practitioners and/or physician assistants). This can be during an annual wellness visit, initial preventative physical exam or other face-to-face visit for new patients or patients not seen within one year prior to the commencement of CCM services (the initiating visit is not part of the CCM service and is separately billed). Otherwise, enrollment of eligible beneficiaries may take place by phone.

Chronic Care Management

Centers for Medicare & Medicaid Services (CMS)

Initiating Visit

Common Chronic Conditions (Among Medicare Patients)