What Is Chronic Care Management, or “CCM?”

If you have Medicare or both Medicare and Medicaid, and have two or more chronic conditions, Medicare is offering CCM services to help you manage your health and spend more time doing the things you enjoy, in good health.

Examples of chronic conditions include, but are not limited to:

• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid)
• Asthma
• Atrial fibrillation
• Autism spectrum disorders
• Cancer
• Cardiovascular disease
• Chronic Obstructive Pulmonary Disease
• Depression
• Diabetes
• Hypertension
• Infectious diseases such as HIV/AIDS
• Substance Use Disorders

What Are the Benefits of CCM?

• Regular CCM means you can better manage your care and spend more time focusing on your health. CCM can help you work toward your health and quality of life goals. Better care management can help you avoid health events such as trips to the emergency department, a fall, or worsening health.
• Coordinated care means you will get personal attention and help from a health care provider you know and who knows about your health conditions and helps to keep you healthy.

Patients must give consent to receive CCM services. This can be given in written form or verbally and documented in the medical record. This documentation in the medical record must include:

1. The patient’s consent to participate in CCM,
2. That the patient was informed that she/he can stop receiving CCM services at any time, and
3. That only one health care professional or hospital can provide CCM in a calendar month.

Information about applicable cost sharing should be included as well.

The language below is intended to be a guide for conversations seeking verbal consent. Please consider the key points listed there.

Your dedicated care team will review your records and may contact you if needed. They may also connect with you about how they are working for you and your health.

• Do you have any questions about the CCM services?
• Do you agree to receive the CCM services?
• Do you understand that a monthly fee could apply to the CCM services?
• How do you prefer to be contacted?
• What is the best time for us to contact you?
• Tip: Refer to “Agency for Healthcare Research and Quality (AHRQ) Use the Teach-Back Method”

This also means that the care team in the practice will share information about your health with me to make sure we can talk about everything when we meet again.

• Do you have any questions about the CCM services?
• Do you agree to receive the CCM services?
• Do you understand a monthly fee could apply to the CCM services?
• How do you prefer to be contacted?
• Tip: Refer to “Agency for Healthcare Research and Quality (AHRQ) Use the Teach-Back Method”

(If applicable): We want to work with [specialist/service agency 1], [specialist/service agency 2], and [specialist/service agency 3] to coordinate care and services for you with the goal of improving your health. This is called chronic care management, or “CCM.”

CCM services will help us work more closely with your other doctors, and help you maintain your health and wellness. If you don’t think you need CCM, you can ask us to stop at any time.

• Do you have any questions about the CCM services?
• Do you agree to receive the CCM services?
• Do you understand that a monthly fee could apply to the CCM services?
• How do you prefer to be contacted?
• Tip: Refer to “Agency for Healthcare Research and Quality (AHRQ) Use the Teach-Back Method”

Please note: The usual cost-sharing rules apply to these services, so many patients are responsible for the usual Medicare Part B cost sharing (deductible and copayment/coinsurance) if they do not have supplemental (“wrap-around”) insurance. Please note that the majority of dual eligible beneficiaries (patients with Medicare-Medicaid) are not responsible for cost-sharing. Medigap plans also provide wrap-around coverage of cost sharing for CCM, with many beneficiaries have Medigap or other supplemental insurance.