Original Medicare (Parts A & B): Chronic Care Management Services

The Centers for Medicare and Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical primary care service that contributes to better health and care.

Your loved one is eligible for CCM if they have 2 or more serious chronic conditions that are expected to last at least a year or until their death, and/or that place them at significant risk of death, acute exacerbation, decompensation, or functional decline. Examples of chronic conditions include but aren't 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 (COPD)

• Depression

• Diabetes

• Hypertension

• Infectious diseases like HIV and AIDS

CCM includes a comprehensive care plan that lists your loved one's health problems and goals, other providers, medications, community services they have and need, and other health information. It also explains the care your loved one needs and how it will be coordinated. CCM and planning include:

• An assessment of your loved one's medical, functional, and psychosocial needs

• Receipt of timely recommended preventive services

• A review of all medications and any potential interactions

• Oversight of your loved one's medication self-management

• Coordination of care with home- and community-based clinical service providers

• Management of care transitions from one provider to another or one care setting to another

If your loved one agrees to get this service, their provider will prepare the care plan for them or you (their caregiver), help you both with medication management, provide 24/7 access for urgent care management needs, give support when your loved one goes from one healthcare setting to another, review their medications and how they're taken, and help with other chronic care needs.

CMS equips providers with comprehensive materials and tools to function in the chronic condition management support role, so they are well-versed in how to help your loved one.

This service is provided for a monthly fee.