Chronic care management (CCM) refers to a Medicare care plan that can help direct a person’s healthcare. It lists information about the individual’s health and also explains the care they require.
Medicare is a federal health program for people 65 years and older. Younger individuals may enroll if they have a specific health condition that makes them eligible. CCM describes a collection of resources available to Medicare beneficiaries with two or more chronic conditions.
Medicare Part A covers hospital, skilled nursing facility, and hospice care costs, and Part B covers doctor visits, durable medical equipment, and other outpatient services.
Part B also includes chronic care management. Older adults with chronic conditions may benefit from this program as it can help to organize care and manage treatments and prescription drugs.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A person with chronic health conditions may benefit from a more tailored health service with a focus on directing care. Chronic care management (CCM) is typically covered under Medicare Part B and is for those who have two or more chronic conditions.
The CCM program helps people manage their health from within the community, offering greater outcomes and higher levels of satisfaction.
A healthcare professional can identify an individual who qualifies for CCM. For example, the need may be recognized during the Medicare annual wellness visit. A doctor, nurse practitioner, or physician assistant can then develop a comprehensive care plan for an individual.
These plans may include:
- recording a person’s health concerns and health information
- keeping comprehensive electronic care plans
- managing care transitions and other care management services
- coordinating and sharing health information
A person must give express permission for this service. They must sign an agreement to confirm they are happy for services to be received outside of a doctor’s office. The goal is to keep a person healthier, with services expected to be delivered every month.
CCM care may include:
- at least 20 minutes a month of care coordination from a healthcare professional
- personalized assistance from a dedicated healthcare professional
- coordination of care between specialists, such as pharmacies, testing centers, and hospitals
- 24/7 emergency access to qualified healthcare professionals
CCM covers a variety of conditions. Examples of chronic conditions include, but aren’t limited to:
Some of the services that can be provided under CCM include:
- health management services
- organizing other healthcare providers by phone, digitally, or in person
- community resource referral, services, and support
- disease education to achieve health management
- health education, including health literacy
- management and coordination of prescription medications
- health coaching
- interventions to reduce risk factors for falls
To qualify for CCM, a person must have a face-to-face visit with a healthcare professional who offers the services.
After signing their agreement, a person has the option to cancel the plan or transfer it to another healthcare professional.
CCM costs with Medicare
Since CCM services are covered under Medicare Part B, individuals are responsible for paying the 20% Part B coinsurance.
Individuals are also responsible for the Part B monthly premium of at least $185 and the Part B deductible, which is $257.
Not all healthcare practitioners provide CCM services, and if a person does not have this option available to them, they can choose to switch primary care providers.
Other community services may also help coordinate medical care.
Program of All-inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) is managed by Medicare and Medicaid. The program helps organize a person’s healthcare needs within the community.
PACE centers must meet federal and state regulations and a team of healthcare providers from a PACE organization coordinates care.
To qualify a person must:
- be ages 55 years or older
- live in a PACE center service area
- have a state-certified need for nursing home care
- be safe in the community using PACE services
Medicaid
Those who qualify for Medicaid may have access to community-based care.
Services include case management, home care, personal care, and transportation. Other plans may not provide coverage for these services.
Extra Help
Medicare has a program for people with limited income to pay for prescription drugs.
The program is called Extra Help, and to qualify, a person must prove they receive other needs-based benefits, such as Medicaid or Supplemental Security Income (SSI).
Chronic health conditions are
Chronic diseases are often costly. Evidence notes that
Common chronic health conditions include:
- Cancer: The American Cancer Society estimates more than
2 millionTrusted Source new cancer diagnoses in the U.S. in 2025. - Diabetes: The Centers for Disease Control and Prevention (CDC) advises that the number of people with diabetes in the U.S. is
38.4 millionTrusted Source . - High blood pressure: Also known as hypertension, the CDC also states that
nearly halfTrusted Source the adults living in the U.S. have high blood pressure. - Heart disease: The American Heart Association (AHA) estimates that as of 2024,
nearly halfTrusted Source of adults over 20 years of age in America have cardiovascular disease. - Obesity: The CDC reports that more than
2 in 5 adultsTrusted Source in the U.S. have obesity.
Other chronic conditions include arthritis, oral disease, and respiratory disease.
Medicare does not limit eligibility to a specific list of health conditions. Conditions that meet the definition of a chronic condition generally qualify for CCM.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
CCM is a service that helps coordinate healthcare for people with at least two chronic health conditions.
Medicare Part B covers the costs of CCM, and a person’s doctor, nurse practitioner, or physician assistant organizes the program. For most Medicare Part B services, a 20% coinsurance will apply, but many Medigap policies can help pay this cost.
Alternative options include the PACE program, Medicaid, and Extra Help.
