Chronic Care Management
A dedicated clinical team that helps you manage multiple chronic conditions, so you spend less energy navigating healthcare and more time living your life.
Someone in your corner, every month
Managing two or more chronic conditions means juggling medications, specialists, lab work, and lifestyle changes, often with little support between office visits. Chronic care management fills that gap.
When you enroll, you are matched with a care manager backed by our physician-led clinical team. Together we build a personalized care plan around your conditions, your medications, and your goals. Then we work that plan with you, month after month.
What chronic care management includes
A personalized care plan
A living document covering your conditions, medications, allergies, providers, and goals, reviewed and updated regularly and shared with your primary care provider.
Monthly check-in calls
A scheduled call with your care manager to review symptoms, medications, and progress toward your goals, and to catch small problems before they become big ones.
Medication management
Medication reconciliation after every hospital visit or prescription change, plus refill support and pharmacy coordination.
Care coordination
We schedule follow-ups, share records between your providers, close referral loops, and make sure specialist recommendations actually reach your care plan.
24/7 access to care
Around-the-clock access to a clinician for urgent questions, so you have somewhere to turn besides the emergency room.
Hospital transition support
After a hospital stay or ER visit, we follow up promptly, reconcile discharge instructions, and help prevent readmission.
A covered Medicare benefit
Chronic care management is recognized and reimbursed by Medicare because it works: consistent monthly coordination reduces hospitalizations and helps patients stay independent longer. You may be eligible if:
- You have Medicare Part B, a Medicare Advantage plan, or comparable coverage
- You live with two or more chronic conditions expected to last 12 months or more
- Your conditions place you at significant risk of decline or hospitalization
Not sure whether you qualify? Our team can check in a single phone call, and enrollment is always your choice.
Check Your EligibilityPairs well with remote monitoring. Many of our patients combine CCM with remote patient monitoring, so their care team sees daily readings and monthly conversations in one place.
Chronic care management FAQ
Who qualifies for chronic care management?
CCM is designed for Medicare patients living with two or more chronic conditions that are expected to last at least twelve months and that place the patient at significant risk. Common qualifying combinations include hypertension with diabetes, heart failure with kidney disease, or COPD with high cholesterol. Many Medicare Advantage and commercial plans offer comparable benefits.
Does CCM replace my primary care doctor?
No. CCM works alongside your existing providers. We coordinate with your primary care provider, share our documentation, and make sure they always have a current picture of your health. Your doctor remains in charge of your overall care.
What does CCM cost?
CCM is a covered Medicare Part B benefit. Depending on your supplemental coverage, a monthly coinsurance may apply; many Medigap and Medicare Advantage plans cover it in full. Our team verifies your coverage and explains any expected cost before you enroll, so there are no surprises.
How much of my time does it take?
Most patients spend about 15 to 20 minutes per month on a call with their care manager. Everything else, including coordination with pharmacies, specialists, and your primary care office, happens behind the scenes.
Can I stop at any time?
Yes. Enrollment is voluntary and you may withdraw at any time with a simple phone call, no questions asked.
Ready to get started?
Talk with our team about enrollment, coverage, and whether chronic care management or remote patient monitoring is right for you or someone you care for.