Chronic Care Management (CCM) Overview & Benefits


CCM Overview 


The Centers for Medicare and Medicaid Services (CMS) defines chronic conditions as those in which the patient is at significant risk of death, acute exacerbation/decompensation, or functional decline, and are expected to last until the death of the patient. 


Chronic disease is rampant in the US, particularly among Medicare patients. Nearly 70% of Medicare beneficiaries have a minimum of two chronic conditions requiring care management, and14% have 6 or more. As the number of chronic conditions for an individual increases, their average costs increase exponentially as well – almost doubling for patients with 2 chronic conditions vs. one, and costing nearly five times as much for patients with three or more.


In 2015 Medicare created a reimbursement program for practices providing (non- complex) chronic disease management to these patients.The program is intended to service Medicare patients with two or more chronic conditions and is a non-face-to-face service. This focus on care coordination is intended to prevent chronic conditions from worsening – preventing unnecessary hospital admissions and ED visits, and saving patients and Medicare money every year.  Overall, Medicare’s CCM program is one of the most important and promising value-based care programs the CMS has established. Also, it’s full of complicated problems and challenges for most practices to use or implement (successfully). 


Chronic Care Management (CCM) is now available to medicare patients that have 2 or more chronic conditions including diabetes, high blood pressure, heart disease, depression, as well as other chronic diseases. The program provides services to assist you in managing your health. Your physician and healthcare team will carefully monitor and assist you with your healthcare to help you set up appointments, identify lab work needs, review medications, and provide a supportive resource for any questions you may have regarding your health.


CCM Programs are seeing an enrollment boost during COVID-19 as patients are getting more open to – and understanding of – the benefits of coordinating care from home. Also, COVID-PHE changes like copay waivers for CCM and RPM specifically are helping.



Benefits of CCM


CCMs provide support to patients to improve their health status and have greater connection and support to the practice. They provide better managed care, and are proven to improve quality of care and health outcomes. In addition, CCM programs provide better tracking of and support to patients, which increases the quality and efficiency of care and brings down costs for providers and the health system overall.  


Specifically, CCMs provide:


– A personalized, comprehensive plan of care for all of your health issues.

– Scheduled preventative care services (many of which are covered by Medicare) and medication management.

– Coordinated care and services provided by your practitioner; including care you may receive at other locations, such as specialists’ offices, the hospital, other healthcare facilities or your home.


Successful CCMs:




Quality of Care

Efficiency of Care

Effectiveness of Care 

Patient Engagement

Patient Satisfaction

Revenue & Reimbursement




Costs of (Chronic) Care


The goal of the Chronic Care Management Program is to provide you with the best care possible, to keep you out of the hospital, and to minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs, or hospitals. 


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