| What You Will Learn | Key Takeaway |
|---|---|
| What chronic care management (CCM) actually is | A Medicare-covered program providing ongoing support for patients with two or more chronic conditions |
| Which conditions qualify | Diabetes, hypertension, heart disease, COPD, arthritis, depression, and many more |
| Who is eligible | Most patients with 2+ chronic conditions lasting 12 months or longer |
| What CCM includes | Monthly check-ins, medication management, care coordination, and 24/7 access to your care team |
| How to get started | Contact Accura Health to find out if you qualify for chronic care management |
Living with a chronic condition is challenging enough. Living with two or more can feel overwhelming, especially when multiple medications, specialist visits, and lifestyle changes are all part of the equation.
That is where Chronic Care Management comes in. Often called CCM, it is a structured healthcare program designed to help patients with multiple chronic conditions receive continuous, coordinated care between office visits. According to the Centers for Medicare and Medicaid Services (CMS), more than 68 percent of Medicare beneficiaries have two or more chronic conditions, and the majority of Medicare spending goes toward managing those conditions.
At Accura Health, we offer Chronic Care Management as part of both our primary care and post-acute care services because managing chronic illness should not stop when you leave the clinic.
What Is Chronic Care Management?
Chronic Care Management is a care coordination program covered by Medicare (and many private insurers) for patients who have two or more chronic conditions expected to last at least 12 months or until the end of life. The program ensures that patients receive at least 20 minutes of non-face-to-face care per month from their provider's team.
This includes:
- Regular monthly check-ins by phone or through our telemedicine platform
- Medication reviews and adjustment recommendations
- Coordination between specialists, pharmacies, and hospitals
- A comprehensive, personalised care plan
- 24/7 access to a member of your care team for urgent health concerns
If you are managing multiple conditions and feel like things slip through the cracks between appointments, CCM is designed exactly for you.
Schedule a CCM consultation at Accura Health today.
Schedule Consultation →Which Conditions Qualify for Chronic Care Management?
The list of qualifying conditions is broader than most patients expect. According to CMS guidelines, any chronic condition expected to last 12 months or more may count. You need at least two from this list (or similar conditions) to be eligible.
Most Common Qualifying Conditions
- Type 1 and Type 2 diabetes
- Hypertension (high blood pressure)
- Congestive heart failure & coronary artery disease
- Chronic obstructive pulmonary disease (COPD)
- Asthma (persistent or moderate-to-severe)
- Osteoarthritis & rheumatoid arthritis
- Depression & anxiety disorders
- Chronic kidney disease
Additional Qualifying Conditions
- Hypothyroidism, hyperthyroidism & obesity (BMI 30+)
- Atrial fibrillation & peripheral vascular disease
- Osteoporosis & chronic back pain
- Alzheimer's disease, dementia & Parkinson's
- Epilepsy & bipolar disorder
- Hepatitis B/C & non-alcoholic fatty liver disease
- Cancer (under active management) & HIV/AIDS
- Lupus, fibromyalgia & other autoimmune disorders
This is not an exhaustive list. If you are living with any combination of ongoing health conditions, our primary care team can evaluate whether you qualify.
Not sure if your conditions qualify? Let our team review your health history.
Check Eligibility →How Do You Know If You Are Eligible?
Eligibility for Chronic Care Management requires three things:
Two or More Qualifying Chronic Conditions
The conditions must be expected to last 12 months or longer, or until the end of life. They do not need to be from the same category. For example, a patient with diabetes and depression qualifies, just as a patient with COPD and chronic kidney disease would.
A Signed Patient Consent
You must provide written or verbal consent to enroll in the program. Your provider will walk you through what is included and how it works. There is no obligation and you may leave the program at any time.
A Comprehensive Care Plan
Your care team will create a detailed plan addressing all of your conditions, medications, goals, and next steps. This plan is reviewed and updated regularly.
If you are unsure whether your conditions qualify, the easiest step is to contact us or bring it up at your next visit. Our team will review your health history and determine eligibility.
What Does Chronic Care Management Look Like at Accura Health?
At Accura Health, CCM is not a checkbox program. It is an extension of the relationship-based care we already provide across our primary care and post-acute care services.
Here is what you can expect:
Monthly Care Coordination
A dedicated member of your care team will check in with you each month to review symptoms, medications, and any changes in your health. These calls typically happen by phone or video through our telemedicine services.
Medication Management
If you are managing multiple prescriptions, our team ensures nothing conflicts, doses are optimised, and refills are on track.
Specialist Coordination
Seeing a cardiologist, endocrinologist, and a mental health provider? We connect the dots between all your providers so nothing falls through the cracks.
24/7 Access
Enrolled patients have access to their care team around the clock for urgent health questions, reducing unnecessary emergency room visits.
For Homebound Patients
For patients who receive care at home through our post-acute care services, CCM integrates seamlessly with our physician housecalls, in-home nursing, and remote patient monitoring programs.
Ready to experience truly coordinated care?
Book an Appointment →Is Chronic Care Management Covered by Insurance?
Medicare: Yes. CCM is a covered benefit under Medicare Part B. Patients are responsible for the standard 20 percent copay, though many supplemental plans cover this as well.
Medicare Advantage: Most Medicare Advantage plans cover CCM services. Coverage details vary by plan. Our team can verify your benefits.
Private Insurance: Many private insurers now offer CCM or similar care management programs. Contact your insurance provider or ask our team to check your eligibility.
Medicaid: Coverage varies by state. In Texas, some Medicaid managed care plans include chronic care management services.
The bottom line is that for most patients with Medicare, the cost barrier is minimal and the health benefits are significant. According to the American Medical Association, patients enrolled in CCM programs have shown reductions in hospital readmissions and emergency department visits.
5 Signs You Should Ask Your Doctor About Chronic Care Management
These are the conversations I have with patients every single day. If any of these sound familiar, it may be time to schedule a consultation with our team.
You Take Medications for Multiple Conditions
You take medications for more than one ongoing condition and sometimes struggle to keep track of dosages, refills, or interactions.
No One Is Coordinating the Bigger Picture
You see multiple specialists but feel like no one is coordinating the bigger picture of your health.
You Have Been Hospitalised or Visited the ER
You have been hospitalised or visited the ER in the past year for a condition that could have been managed earlier.
You Feel Overwhelmed Managing Your Health
You feel overwhelmed trying to manage diet, exercise, medications, and appointments across several conditions at once.
You Need Consistent Support Between Visits
You are homebound or have limited mobility and need consistent medical support between in-person visits. Our physician housecalls and remote patient monitoring can help bridge that gap.
Key Takeaways
- Chronic Care Management is a Medicare-covered program for patients with two or more chronic conditions lasting 12 months or longer.
- Qualifying conditions include diabetes, hypertension, COPD, heart disease, depression, arthritis, chronic kidney disease, and many others.
- CCM provides monthly check-ins, medication management, specialist coordination, and 24/7 care team access.
- At Accura Health, CCM is integrated across both primary care and post-acute care, including telemedicine and in-home services.
- Most patients with Medicare pay little to no out-of-pocket cost for this program.
- If you have two or more chronic conditions and feel things are slipping through the cracks, it is time to ask about CCM.
Take the first step toward better-managed chronic care.
If you have two or more chronic conditions and want ongoing support between visits, we are here to help.
Regular visits address immediate concerns during a scheduled appointment. CCM provides continuous care between visits, including monthly check-ins, medication reviews, and coordination across all your providers. It ensures nothing gets missed between appointments.
Yes. While Medicare Part B is the most common payer, many Medicare Advantage and private insurance plans also cover chronic care management services. Ask our team to verify your benefits.
No. Most CCM interactions happen by phone or video. For homebound patients, our post-acute care team can integrate CCM with in-home visits and remote patient monitoring.
Absolutely. Enrollment is voluntary. You may opt out at any time by notifying your care team. There is no penalty for leaving the program.
Simply call us at (972) 430-2040 or book an appointment online. We will review your conditions, confirm eligibility, and walk you through the enrollment process.
References
- Centers for Medicare and Medicaid Services. Chronic Care Management Services. cms.gov
- American Medical Association. Chronic Care Management: What Physicians Need to Know. ama-assn.org
- Centers for Disease Control and Prevention. About Chronic Diseases. cdc.gov
This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider regarding any medical condition, diagnosis, or treatment.
