Chronic Care · Medicare · Care Coordination
CCM
Medicare
Care Coordination
Managing one chronic condition takes steady effort. Managing two or more, such as diabetes and high blood pressure, or arthritis and heart disease, calls for coordination that rarely fits inside a routine office visit.
Chronic Care Management (CCM) is the Medicare program built for exactly that gap. It pays a patient’s practice to coordinate care between appointments, keeping medications, specialists, and follow-ups connected across the month. According to the Centers for Medicare & Medicaid Services (CMS), roughly two-thirds of people with Medicare live with two or more chronic conditions, so a large share of Medicare patients may qualify.
This guide explains what CCM covers, who is eligible, what the program requires each month, and what changed for CCM in 2026.
What Chronic Care Management Is
CCM is a service delivered by a patient’s health care team outside of regular office visits. It acts as a bridge that connects care between appointments.
Instead of a patient trying to remember what the cardiologist told them to relay to their primary care doctor, a CCM care coordinator helps keep every provider working from the same information.
CCM services are directed by physicians or other qualified health care professionals (QHCPs), such as nurse practitioners and physician assistants, and are often carried out by clinical staff under their supervision. The service was established as a separately billable Medicare benefit in 2015 and has expanded through later rulemaking.
Who Qualifies for CCM
Eligibility is based on the complexity of a patient’s health, not on a single diagnosis. To qualify for CCM under Medicare, CMS sets three criteria.
Multiple conditions. The patient has two or more chronic conditions.
Duration. Those conditions are expected to last at least 12 months, or until the death of the patient.
Significant risk. The practitioner determines the conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
CMS notes that practitioners may also weigh the number of medications, repeat admissions, or recent emergency department (ED) visits when identifying candidates. Examples of qualifying conditions include heart disease, diabetes, chronic kidney disease, chronic lung disease, depression, and dementia, among others.
What Services CCM Includes
When a patient enrolls, the billing practice provides at least 20 minutes of dedicated staff time each month focused on that patient’s care. The service covers more than documentation. Required elements include the following.
| Service Element | What It Means for the Patient |
|---|---|
| Dedicated monthly time | At least 20 minutes of care coordination per calendar month, tracked and documented. |
| 24/7 access to care | Round-the-clock access to a member of the care team for urgent care needs. This supports coordination and is not a substitute for emergency care; patients with an emergency should still call 911. |
| Comprehensive care plan | An electronic care plan covering conditions, medications, history, and goals, shared with the care team to reduce duplicative or conflicting treatment. |
| Medication management | Regular medication review, which matters most when prescriptions come from several different providers. |
| Care transition support | Coordination after a hospital or skilled nursing discharge to help reduce the risk of readmission. |
The Rules Patients Should Know
The CMS guidance highlights a few rules worth understanding before enrolling.
The one-provider rule. Only one practitioner or hospital can be paid by Medicare for managing a patient’s chronic care in a given calendar month. A patient cannot sign up for CCM with both a cardiologist and a primary care doctor at the same time and must choose one to lead the coordination.
The right to stop. A patient can stop CCM services at any time, effective at the end of the calendar month.
Consent. The patient must give verbal or written consent to participate, and must be informed that cost-sharing may apply. Consent is obtained once and only needs to be repeated if the billing practitioner changes.
What CCM Costs and the 2026 Copay Bill
CCM carries the standard Medicare Part B coinsurance of 20 percent, which usually works out to roughly $8 to $15 per month depending on the specific code billed and local pricing.
Patients with supplemental coverage such as Medigap, or those dually enrolled in Medicare and Medicaid, often have this amount offset already.
A bipartisan bill in Congress could change that. H.R.8261, the Chronic Care Management Improvement Act of 2026, would eliminate cost-sharing for CCM under Medicare. It was introduced on April 14, 2026, and remains in the early committee stage of the legislative process, so the 20 percent coinsurance stays in effect for now. You can read more in our overview of what H.R.8261 would mean for practices running CCM programs.
What Changed in 2026
Under the CY 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F), effective January 1, 2026, CMS increased payment for CCM services by roughly 10 percent and did not add new CCM codes. The base code for 20 minutes of staff-led coordination remains the reference point for most practices.
The Benefits Backed by CMS Data
A CMS-commissioned evaluation reviewed two years of nationwide claims comparing CCM enrollees with a matched group not receiving the service. The findings were consistent across the population.
Beyond the figures, patients often describe a sense of reassurance in knowing someone is helping keep their care organized even when they are not sitting in the doctor’s office.
How DrKumo Supports CCM Program Delivery
DrKumo provides secure, HIPAA-compliant digital health technology that supports the care coordination workflows at the center of CCM. One of the biggest hurdles in managing several conditions is the ongoing work of logging blood pressure, tracking glucose, and reporting it back.
DrKumo supports this by offering technology in which medical devices as defined by the FDA, such as connected scales or blood pressure cuffs, transmit readings to the care team automatically when a patient uses them. This gives clinicians accurate, between-visit visibility rather than a single snapshot at a monthly appointment.
The platform supports Remote Patient Monitoring (RPM) alongside CCM, giving care teams both physiologic data and the structured coordination CCM requires. For organizations building a comprehensive RPM program, it is worth noting that RPM is for monitoring only and does not replace in-person clinical evaluation or emergency care.
This is especially relevant for FQHCs and RHCs serving patients with high chronic-disease burdens. DrKumo’s technology also supports provider-led Disease Management Protocols (DMPs) for the conditions most common among these patients, including hypertension, diabetes, heart failure, and COPD.
Importantly, DrKumo is not a clinical entity and does not provide clinical services. Practices and their licensed providers retain full responsibility for clinical decisions, billing, and patient care. DrKumo supplies the secure infrastructure that helps those care teams do the work.
Key Takeaways
Chronic Care Management gives Medicare patients with two or more chronic conditions structured support between office visits, coordinated by their own care team.
Eligibility rests on having two or more conditions expected to last at least 12 months that place the patient at significant risk. The billing practice must provide at least 20 minutes of coordination each month, a comprehensive care plan, and 24/7 access for urgent needs.
CMS evaluation data links CCM enrollment to fewer hospitalizations and emergency department visits and lower monthly Medicare costs. A 20 percent copay currently applies, though H.R.8261 could remove it if passed.
Technology can ease the day-to-day monitoring that supports coordinated care, but the clinical work stays with the practice. DrKumo is a technology provider, not a clinical entity, and supports the teams delivering these programs.
Coordinated Care Starts Here
Build the chronic care infrastructure your patients need between visits.
To learn how DrKumo can support your practice in delivering secure, HIPAA-compliant Chronic Care Management, contact us today. Our team is ready to support your journey toward better patient care.
Frequently Asked Questions
Common questions about Chronic Care Management eligibility, cost, and how the program works.
References
Centers for Medicare & Medicaid Services. Chronic Care Management Services (MLN909188). CMS.gov.
Centers for Medicare & Medicaid Services. Connected Care: Chronic Care Management Toolkit. CMS.gov.
Centers for Medicare & Medicaid Services. Evaluation of the Diffusion and Impact of the Chronic Care Management Services: Final Report. CMS Innovation Center.
Centers for Medicare & Medicaid Services. Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F). CMS.gov.
U.S. Congress. H.R.8261, Chronic Care Management Improvement Act of 2026. Congress.gov.
American Hospital Association. Support for the Chronic Care Management Improvement Act of 2026. AHA.org.
