Medicare uses chronic care management to help direct a person’s healthcare. This can reduce the number of hospital visits needed and keeps costs to a minimum.
Medicare is a federal health program for people aged 65 years and older. Younger individuals may enroll if they have a specific health condition that makes them eligible.
Medicare Part A covers costs in hospitals, skilled nursing facilities, and nursing home care, and Part B covers costs for doctor visits, durable medical equipment, and other outpatient services.
Part B also includes chronic care management. Older adults with chronic conditions may benefit from this program as it can help to organize care and manage treatments and prescription drugs.
In this article, we discuss Medicare coverage for chronic care management, how to get it, and what other options are available.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Chronic health conditions are broadly defined as conditions expected to last one year or more, require ongoing medical care, or limit a person’s activities.
Chronic diseases are often costly. Nearly half of all people in the United States suffer from at least one chronic condition.
Common chronic health conditions include:
- Cancer: the American Cancer Society estimates
1,762,450new cancer diagnoses.
- Diabetes: the Centers for Disease Control and Prevention (CDC) advises that the number of people with diabetes in the U.S. is
- High blood pressure: the CDC also states that
nearly halfthe people living in the U.S. have high blood pressure.
- Heart disease: the American Heart Association expects 1,055,000 heart events.
- Obesity: the CDC reports the percentage of people in the U.S. who are overweight or obese as
Other chronic conditions include arthritis, oral disease, and respiratory disease.
Medicare does not limit eligibility to a specific list of health conditions. Conditions that can qualify are expected to last at least 12 months, and are expected to increase the risk of going to the hospital, long term disability, or loss of life.
A person with chronic health conditions may benefit from a more tailored health service with a focus on directing care.
Chronic care management (CCM) is normally covered under the Medicare Part B benefit and is for those who have two or more chronic conditions.
The CCM program provides help for a person to manage their health from within the community and can offer greater outcomes and better levels of satisfaction.
A healthcare provider will identify an individual who qualifies for CCM. For example, the need may be recognized during the Medicare annual wellness visit.
A doctor, nurse practitioner, or physician assistant will then develop a care plan for an individual.
The plan usually includes:
- a person’s health concerns
- the healthcare providers they need
- details of prescribed medications
- any community services required
A person must give express permission for this service. They must sign an agreement to confirm they are happy for services to be received outside of a doctor’s office.
The goal is to keep a person healthier, with services expected to be delivered every month.
Some of the services that can be provided under CCM include:
- health management services
- organizing other healthcare providers by phone, digitally, or in-person
- community resource referral, services, and support
- disease education to achieve health management
- health education, including health literacy
- management and coordination of prescription medications
- health coaching
- interventions to reduce risk factors for falls
To qualify for CCM, a person must have a face-to-face visit with a healthcare provider who offers the services.
After signing their agreement, a person can cancel the plan or transfer it to another healthcare provider.
The same as any other outpatient service, Medicare Part B has a coinsurance of 20% for services included on a CCM plan. The person receiving the services is responsible for this amount.
Plans such as Medigap or Medicaid can help with out-of-pocket costs.
Not all healthcare practitioners provide CCM services, and if a person does not have this option available to them, they can choose to switch primary care providers.
Other community services may also help coordinate medical care.
Program of All-inclusive Care for the Elderly (PACE)
The Program of All-Inclusive Care for the Elderly (PACE) is managed by Medicare and Medicaid. The program helps organize a person’s healthcare needs within the community.
PACE centers must meet federal and state regulations and a team of healthcare providers from a PACE organization coordinates care.
To qualify a person must:
- have Medicare, Medicaid, or both
- be aged 55 years or older
- live in a PACE center service area
- have a state-certified need for nursing home care
- be safe in the community using PACE services
Those who qualify for Medicaid may have access to community-based care.
Services include case management, home care, personal care, and transportation. Other plans may not provide coverage for these services.
Medicare has a program for people with limited income to pay for prescription drugs.
The program is called Extra Help, and to qualify, a person must prove they receive other needs-based benefits, such as Medicaid or Supplemental Security Income (SSI).
Chronic care management is a service that helps coordinate healthcare for people with at least two chronic health conditions.
Medicare Part B covers the costs of CCM, and a person’s doctor, nurse practitioner, or physician assistant organizes the program.
For most Medicare Part B services, a 20% coinsurance will apply, but many Medigap policies can help pay this cost.
People who have Medicaid and Medicare are dual-eligible beneficiaries. In this case, Medicaid would pay the 20% coinsurance.
Alternative options include the Program of All-Inclusive Care for the Elderly (PACE) program, Medicaid, and Extra Help.