Chronic Care Management: the monthly benefit hiding in plain sight

About two-thirds of people in Traditional Medicare live with two or more chronic conditions. Almost all of them qualify for Chronic Care Management. A small fraction receive it.

The benefit has existed since 2015 — considerably longer than PIN and CHI — and it's the most widely applicable of Medicare's coordination services. It's also the one families are least likely to be offered, because delivering it well requires a practice to staff for work that happens between appointments, which is not how most practices are built.

The bar is deliberately low:

• Two or more chronic conditions.
• Expected to last at least 12 months, or until the end of life.
• Placing the patient at significant risk of death, acute worsening, or functional decline.

There's no official list of qualifying conditions. Diabetes, hypertension, heart failure, COPD, arthritis, atrial fibrillation, chronic kidney disease, depression, osteoporosis, cancer, dementia — any two of these, in combination, generally clears it. So does a great deal else.

CCM isn't a phone call every so often. Medicare specifies what the practice must deliver, and the list is worth knowing so you can tell whether you're getting it:

1. 1.At least 20 minutes per calendar month of clinical staff time directed at care management, outside of face-to-face visits.
2. 2.A comprehensive, electronic care plan covering all conditions, with goals, medications, community resources and the other providers involved — and the patient gets a copy.
3. 3.Management of care transitions between providers and settings, with timely exchange of records.
4. 4.Medication reconciliation and oversight of self-management.
5. 5.Coordination with home and community-based service providers.
6. 6.24/7 access to a care team member who can address urgent needs and who has access to the electronic care plan.
7. 7.A designated member of the care team for successive routine appointments.

Item six is the one families underuse and shouldn't. Round-the-clock access to someone who can see the actual record is what turns an alarming Saturday night into a phone call rather than an emergency department visit.

CCM is a Part B service billed monthly. The annual deductible applies, then 20% coinsurance. As with the other coordination benefits, Medigap, Medicaid or retiree coverage typically absorbs the coinsurance, leaving nothing for the family to pay.

Consent is required before it starts, and the patient must be told about the cost-sharing and their right to stop at any time — the same protections that apply to PIN and CHI. There's also a complex version of the benefit for patients requiring substantially more time and clinical decision-making each month.

Medicare has accumulated five overlapping coordination services. They are genuinely different, and a practice usually can't bill two of them for the same work in the same month.

The distinctions in practice: CCM is the broad, steady one for multiple ongoing conditions. PIN is for when one condition becomes serious enough to dominate. CHI is for when the obstacle isn't the illness at all. TCM is the 30-day sprint after a discharge — the highest-risk window in healthcare, and worth asking about every single time someone comes home.

This goes to the primary care practice, which is where CCM usually lives.

1. 1.Ask directly: "Does this practice offer Chronic Care Management? My mother has diabetes and heart failure and we'd like to enrol."
2. 2.If yes, expect a conversation about consent and cost-sharing, and expect to be told who the designated care team member is.
3. 3.Ask for the written care plan. It's a required part of the service and the patient is entitled to a copy — it's also genuinely the most useful single document a complex patient can have.
4. 4.Ask for the 24/7 number, and put it in the phone before you need it.
5. 5.If the answer is no, ask whether they'd consider it, and ask what they do offer instead. Some practices run equivalent programmes under different names.

And if the practice can't offer it, that's the point at which it's worth looking at whether another practice can. Coordination is a service like any other; it doesn't have to come from the same building as everything else.