---
title: What is Chronic Care Management? A Patient's Guide
description: Get clear answers to what is chronic care management (CCM), how it works, who qualifies, and the real benefits for patients and healthcare providers.
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---
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# What Is Chronic Care Management? Services, Eligibility, and Costs
Author: [Andy Scott](https://www.1bioshealth.com/blog/author/andy-scott)
Last updated: October 21, 2026
Tags: [Chronic Care Management (CCM)](https://www.1bioshealth.com/blog/tag/chronic-care-management-ccm)
Managing several chronic conditions can involve more than a patient and physician can address during an office visit. Medication questions arise, specialist appointments need follow-up, and changes in a patient’s daily life can make a care plan harder to follow. Chronic care management provides a structured way to support patients between those visits.
**Chronic care management (CCM) is ongoing care coordination for people with multiple chronic conditions.** It can include medication support, a personalized care plan, communication among providers, and help navigating care transitions. Medicare covers CCM for eligible patients when the applicable service requirements are met, and patient cost-sharing may apply.
At [1bios](https://www.1bioshealth.com/), our approach is simple: **You already have the patients. We bring the operation.** We help practices organize the people, workflows, and documentation behind connected care. Understanding what CCM involves is the first step toward deciding how it should fit your patients and practice.
## Chronic care management at a glance
- **What CCM is:** Chronic care management is ongoing care coordination for people with multiple chronic conditions, with support between office visits.
- **What it includes:** Services can include a personalized care plan, medication support, communication among providers, and help during care transitions.
- **Who qualifies under Medicare:** Patients need at least two chronic conditions expected to last at least 12 months or until death, with significant risk of death, exacerbation, decompensation, or functional decline. All applicable requirements must be met.
- **What patients may pay:** Under Original Medicare, the Part B deductible applies, followed generally by 20% coinsurance. Other coverage may affect the patient's final cost.
- **How it differs from RPM:** CCM focuses on care coordination. Remote patient monitoring uses connected devices to transmit health measurements for review and management; a device is not a universal CCM requirement.
Sources: [CMS CCM guidance](https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf) and [Medicare CCM coverage](https://www.medicare.gov/coverage/chronic-care-management-services). Coverage and patient costs should be verified for the individual plan.
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## What services does chronic care management include?
CCM connects the different parts of a patient’s ongoing care. [Medicare describes CCM services](https://www.medicare.gov/coverage/chronic-care-management-services) as including a comprehensive care plan, medication review, support during care transitions, and access for urgent care needs. The work should reflect the individual patient’s needs rather than follow the same conversation every month.
For a practice, the operational challenge is making sure someone owns each follow-up. If a patient reports difficulty obtaining medication, the next step needs an assigned person and a documented outcome. If an issue needs a clinician’s decision, the care team needs a clear route to that clinician.
| Service | Practical example | Intended follow-through |
| --- | --- | --- |
| Care-plan support | A patient reports that transportation difficulties are making the current follow-up plan hard to follow. | Bring the barrier to the care team and update the plan as appropriate. |
| Medication coordination | A patient identifies a difference between a discharge medication list and the list used before hospitalization. | Route the discrepancy to the appropriate clinician or pharmacist and confirm that clarified instructions reach the patient. |
| Communication with other providers | The practice needs a specialist's recommendations to coordinate the patient's ongoing care. | Request the relevant information, route it for review, and identify any unresolved questions. |
| Care-transition support | A patient returns home after a hospitalization with follow-up appointments and care instructions. | Help coordinate the next steps and check whether the patient can follow the instructions. |
| Patient education | A patient has questions about how to follow the agreed care plan at home. | Explain within the team member's role, check understanding, and route clinical questions to the appropriate clinician. |
| Connections to community resources | A patient reports difficulty accessing transportation or other support needed for care. | Identify appropriate resources and follow up on whether the patient was able to connect. |
Illustrative examples, not universal service commitments or a complete Medicare checklist. Activities should reflect individual patient needs, staff qualifications, and the practice's care plan and service arrangements.
### A personalized care plan
A care plan brings the patient’s health concerns, goals, medications, and care needs together. It should help the patient and care team understand what they are working toward and how different providers contribute. As circumstances change, the plan should remain useful to the people relying on it.
### Medication and follow-up support
Medication support may involve identifying questions, understanding barriers, and coordinating with the appropriate clinician or pharmacy. It does not mean that every care-team member independently changes treatment. The workflow should distinguish an issue the team can resolve from a decision that needs a prescribing clinician.
### Coordination across providers and settings
A patient may receive instructions from a primary care practice, specialists, and a hospital discharge team. CCM helps connect those instructions and identify unresolved questions. A practical process also checks whether the next step happened, rather than treating a referral or message as the end of the work.
## Who qualifies for chronic care management?
For Medicare CCM, a patient must have at least two chronic conditions expected to last at least 12 months or until death. Those conditions must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. Having two diagnoses is therefore a starting point, not the complete eligibility determination. [CMS explains these eligibility criteria](https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/chronic-care-management-complex-conditions).
Conditions such as diabetes, heart failure, and chronic obstructive pulmonary disease can be relevant to that assessment. The practitioner still needs to evaluate the patient’s circumstances and whether the service is appropriate. Our guide to [which conditions qualify for CCM](https://www.1bioshealth.com/blog/which-conditions-qualify-for-ccm-a-practical-guide-for-providers) explores eligibility in more detail.
## How does CCM work for a patient?
A patient should understand what support is being offered before joining a CCM program. The enrollment conversation should explain the care team’s role, how to reach the team, and any expected financial responsibility. It should also give the patient a chance to ask how CCM will work alongside existing appointments and providers.
The practice then needs a dependable process for providing care and following up. Patients should know whom to contact, while staff should know where to document concerns and route clinical questions. The following stages describe a practical workflow rather than a fixed schedule that every program must follow.
1. **Review eligibility and care needs.** Determine whether CCM is appropriate for the patient.
2. **Explain the service and document consent.** Discuss participation, communication, and potential costs.
3. **Establish the care plan and contacts.** Make responsibilities and next steps clear.
4. **Provide ongoing support.** Address patient-specific needs between visits.
5. **Follow through and document the work.** Record actions, unresolved issues, and clinician responses.
An initiating visit may also be required under Medicare rules. Practices should check this during enrollment rather than assume every patient follows the same path. The detailed requirements belong in the practice’s enrollment process and [CCM program launch plan](https://www.1bioshealth.com/blog/chronic-care-management-program).
## A practical example of CCM between office visits
Consider a patient with diabetes and heart failure who has recently returned home from the hospital. During an illustrative CCM interaction, the patient reports that the medication list from discharge differs from the list used before admission. The patient also has not scheduled the recommended follow-up appointment.
The care-team member documents the discrepancy and routes it to the appropriate clinician for reconciliation. The team helps coordinate the follow-up appointment and checks whether the patient received the clarified instructions. The care record then shows what was identified, who addressed it, and what remains open.
The value of this workflow is the completed follow-through. A phone call alone would not resolve the conflicting instructions. Someone needs to take responsibility for moving the question to the right person and communicating the answer back to the patient.
## Does Medicare cover chronic care management, and what does it cost?
Medicare Part B covers CCM for eligible patients when requirements are met. Under Original Medicare, the Part B deductible applies, and patients generally pay 20% of the Medicare-approved amount after meeting it. Supplemental coverage or other assistance may affect the patient’s final responsibility. [Medicare’s CCM coverage information](https://www.medicare.gov/coverage/chronic-care-management-services) explains the basic cost-sharing arrangement.
Practices should avoid describing CCM as automatically free for Medicare patients. Explain expected costs before enrollment and give patients a contact for billing questions. For a fuller discussion, see [Medicare and chronic care management](https://www.1bioshealth.com/blog/chronic-care-management-medicare).
Coverage outside Original Medicare should be verified with the patient’s plan. Do not assume that another payer follows every Medicare billing rule or payment arrangement. The enrollment workflow should identify who performs that verification and how the result is communicated.
## Is CCM the same as remote patient monitoring?
**CCM and remote patient monitoring are related but different services.** CCM focuses on ongoing coordination across a patient’s chronic care needs. RPM uses connected medical devices to transmit health measurements, such as blood pressure or weight, for review and management. [CMS describes how RPM works](https://www.cms.gov/medicare/coverage/telehealth/remote-patient-monitoring).
A CCM program does not automatically include a connected device. Likewise, receiving a device does not establish that a patient is receiving comprehensive CCM services. A practice offering both needs to define the responsibilities and documentation for each.
| Question | Chronic care management (CCM) | Remote patient monitoring (RPM) |
| --- | --- | --- |
| What is the primary purpose? | Coordinate ongoing care for patients with multiple qualifying chronic conditions. | Collect and use remotely transmitted physiologic measurements to help manage an acute or chronic condition. |
| Is a connected device required? | A connected monitoring device is not a universal CCM requirement. | Connected medical devices collect and digitally transmit measurements such as blood pressure or weight. |
| What activities may be involved? | Care-plan support, medication coordination, communication among providers, and help during care transitions. | Device setup and education, data transmission, review of measurements, and treatment-management communication. |
| What does the practice need to organize? | Patient selection, enrollment, care coordination, clinical escalation, documentation, and billing review. | Patient selection, enrollment, device access and activation, missing-reading follow-up, reading review, escalation, documentation, and billing review. |
| Does one service automatically include the other? | No. CCM enrollment does not establish that a patient is receiving RPM. | No. Receiving a monitoring device does not establish that a patient is receiving CCM. |
Each service has its own eligibility, service, documentation, and billing requirements. This is an operational comparison, not a code-selection checklist. Sources: [CMS CCM guidance](https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf) and [CMS RPM overview](https://www.cms.gov/medicare/coverage/telehealth/remote-patient-monitoring).
## Who provides chronic care management?
CCM can involve a billing physician or other qualified practitioner and clinical staff working within applicable requirements. An outside care-management team may perform agreed functions, but outsourcing does not eliminate the billing practitioner’s involvement. [CMS’s CCM FAQs](https://www.cms.gov/files/document/chronic-care-management-faqs.pdf) explain the distinction between delegated clinical-staff work and retained practitioner responsibilities.
Practices can organize the work internally, use a partner, or divide responsibilities between the two. The practical question is who owns enrollment, patient outreach, clinical escalation, documentation, and unresolved follow-up. Our [in-house versus outsourced CCM comparison](https://www.1bioshealth.com/blog/outsourced-ccm) examines those operating choices.
Patients should also receive clear instructions about the program’s contact arrangements. Access for urgent care needs should not be described as continuous surveillance or a promise of an immediate response to every message. The practice and any partner should define their coverage arrangements and patient instructions explicitly.
## How is CCM documented and billed?
CCM billing depends on the service delivered and the applicable code requirements. Different code families distinguish clinical-staff work, services personally furnished by the billing practitioner, and complex CCM. Practices should use a detailed [CCM CPT code reference](https://www.1bioshealth.com/blog/chronic-care-management-cpt-codes) rather than treat every patient as having the same monthly billing requirement.
Operationally, the record should connect the patient’s needs with the work performed. A reviewer should be able to identify the activity, the person responsible, and any outstanding question. If information is incomplete, the team needs a process for investigating it before the record reaches final claim review.
Documentation support does not guarantee reimbursement. A time total or completed template should not replace review of the underlying service. The practice’s billing process remains responsible for checking whether a claim is supported.
## How can 1bios help a practice deliver CCM?
1bios supports practices with the operational work behind connected care, including agreed care-management, documentation, and billing-support functions. The practice retains clinical direction and should have a clear understanding of the responsibilities assigned to each team. In the standard 1bios CCM model, the practice’s billing team submits claims and collects reimbursement.
A useful starting conversation looks at where follow-through currently breaks down. That may be patient outreach, unanswered clinical questions, inconsistent documentation, or unclear handoffs to billing. Defining those gaps helps the practice evaluate the support it actually needs.
**You already have the patients. We bring the operation.**
Talk with 1bios about the people, workflows, and documentation needed to support your CCM patients between visits.
[Explore CCM with 1bios](https://www.1bioshealth.com/)
### Related articles
- [Which Conditions Qualify for CCM?](https://www.1bioshealth.com/blog/which-conditions-qualify-for-ccm-a-practical-guide-for-providers)
- [How to Start a Chronic Care Management Program](https://www.1bioshealth.com/blog/chronic-care-management-program)
- [In-House vs. Outsourced CCM](https://www.1bioshealth.com/blog/outsourced-ccm)
- [CCM CPT Codes and Billing Requirements](https://www.1bioshealth.com/blog/chronic-care-management-cpt-codes)
## Frequently asked questions
### Is chronic care management just a monthly phone call?
No. A phone conversation may be one part of CCM, but the service involves broader care coordination. The important question is what needs were addressed and what follow-up occurred.
### Does CCM replace regular doctor appointments?
No. CCM supports care between appointments. Patients should continue the visits and other care recommended by their treating clinicians.
### Do patients need a monitoring device for CCM?
No. A connected monitoring device is associated with RPM rather than being a universal CCM requirement. A practice may offer both services when appropriate, but it should explain each separately.
### What should patients ask before joining a CCM program?
Ask who will contact you, how to reach the care team, and how the service works with your existing providers. Ask about expected costs and how to raise questions about participation. You should understand the service before agreeing to it.
### What should a practice decide before offering CCM?
Start by assigning responsibility for enrollment, ongoing care, clinical questions, documentation, and billing review. Confirm how those responsibilities will work during absences and when follow-up is delayed. The operating plan should make it clear who takes the next step when something remains unresolved.
[Andy Scott](https://www.1bioshealth.com/blog/author/andy-scott)
Andy Scott is the founder and CEO of 1bios, where technology, data, and care delivery come together to help patients and providers succeed. Over the past decade, he has built 1bios into a leading remote patient monitoring and virtual care management platform trusted by thousands of providers and hundreds of thousands of patients. His work helps healthcare organizations thrive while empowering patients to live healthier, more connected lives.
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##### Table of Contents
### Related Articles:
#### [ 6 Proven Strategies to Keep Patients Active in RPM and CCM Programs](https://www.1bioshealth.com/blog/how-to-improve-patient-engagement-in-rpm-and-ccm)
#### [ CMS Proposed Rule Would Expand Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)](https://www.1bioshealth.com/blog/2022-cms-proposed-rule-would-expand-remote-patient-monitoring-and-chronic-care-management)
#### [ Medicare and Chronic Care Management: How It Works & Why It Matters](https://www.1bioshealth.com/blog/chronic-care-management-medicare)
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