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What is CCM?

Chronic Care Management (CCM) is a Medicare Part B service that covers non-face-to-face care coordination for patients with multiple serious chronic conditions. It helps patients with two or more long-term health conditions manage their health through a personalized care plan, 24/7 urgent access to care, and regular support between office visits. (Medicare.gov)

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What does CCM Provide?

- A comprehensive digital care plan tracking health goals

- 24/7 access to a member of your care team

- Help coordinating care across different specialists, providers and facilities. We schedule visits and keep your care plan on track

- Regular medication reviews and management support

- Monthly non-face-to-face check-ins by phone or secure messaging (Medicare.gov)

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Cost And Coverage

CCM services are covered under Medicare Part B. Total out-of-pocket costs are determined by secondary insurance coverage and deductible status. Standard Part B 20% coinsurance may apply, depending on secondary insurance or dual Medicaid eligibility

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Patient Eligibility

- Must have Original Medicare or a Medicare Advantage plan

- Must have two or more chronic conditions expected to last at least 12 months

- Conditions must place the patient at significant risk of health decline

- Must provide verbal or written consent to the provider. (Medicare.gov)

It is not time limited. You can participate in the program as long as you need it or you continue to meet the eligibility requirements.

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What is a Chronic Condition?

A chronic condition is a long-term health problem. It generally lasts for one year or longer. It needs ongoing medical care. It can also make daily tasks hard to do. (Center for Disease Control and Prevention. cdc.gov) Such human health issue or disease generally cannot be prevented by vaccines or completely cured by medications.

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Qualifying Chronic Conditions

- Cardiovascular: Hypertension, Ischemic Heart Disease, Congestive Heart Failure (CHF).

- Neurological & Mental Health: Alzheimer’s disease/Dementia, Depression, Anxiety.

- Respiratory: Asthma, Chronic Obstructive Pulmonary Disease (COPD).

- Systemic: Osteoarthritis, Rheumatoid Arthritis, Cancer, and HIV/AIDS.

- Metabolic & Endocrine: Diabetes Mellitus, Chronic Kidney Disease (CKD), Obesity.

And Many More

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Requirements

Diagnosis: Must live with two or more long-term illnesses that require continuous care over the next year or longer.

Consent: Needs a face to face visit first to make a care plan and get patient approval.

Coverage: Billed under Medicare Part B

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Core Program Services

Care Coordination: Managing transitions between hospitals, specialists, and primary care.

Medication Oversight: Reviewing prescriptions, adherence, and interactions.

Continuous Access: Providing 24/7 urgent clinical support and routine remote check-ins

Time Commitment: Involves at least 20 minutes (non-complex) or 60 minutes (complex) of clinical staff time per month

Ready to sign up for CCM?

Talk to your healthcare provider and let us coordinate with your care team.

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Key Rules to Keep in Mind