Discover the Benefits of Medicare’s Chronic Care Management (CCM) Program
If you live with two or more chronic conditions like diabetes, high blood pressure, arthritis, or heart disease, you may qualify for a special Medicare program that offers extra support between your regular doctor visits.
This program is called Chronic Care Management (CCM)—and it’s designed to make life easier for seniors managing long-term health issues.
What Is Chronic Care Management?
CCM gives you monthly support from your care team, helping you stay on top of your health without needing extra office visits. You’ll have a dedicated care coordinator who checks in regularly, helps manage your medications, arranges follow-ups, and is available to answer questions anytime—even after hours.
What’s Included:
✅ A personal care plan tailored to your needs
✅ Monthly check-ins by phone
✅ Help managing your medications and appointments
✅ Coordination between all your doctors and specialists
✅ 24/7 access to a care team for urgent needs
✅ Support after hospital stays or ER visits
What is the cost?
This program is covered by Medicare, and many patients have supplemental insurance (like Medigap) to cover any copay. Ask your provider if this applies to you.
We also have hardship waivers for those who may not be able to cover the cost.
Common Chronic Diagnosis
This list is not exhaustive but reflects the most common conditions qualifying patients for chronic care services.
Cardiovascular
- Hypertension (I10)
- Coronary Artery Disease (I25.10)
- Congestive Heart Failure (I50.9)
- Atrial Fibrillation (I48.91)
- Hyperlipidemia (E78.5)
- Peripheral Artery Disease (I73.9)
Endocrine
- Type 2 Diabetes Mellitus (E11.9)
- Hypothyroidism (E03.9)
- Obesity (E66.9)
- Metabolic Syndrome (E88.81)
Respiratory
- Chronic Obstructive Pulmonary Disease (COPD) (J44.9)
- Asthma (J45.909)
- Sleep Apnea (G47.33)
Musculoskeletal
- Osteoarthritis (M19.90)
- Rheumatoid Arthritis (M06.9)
- Osteoporosis (M81.0)
- Chronic Back Pain (M54.5)
Neurological
- Alzheimer’s Disease (G30.9)
- Dementia (F03.90)
- Parkinson’s Disease (G20)
- Epilepsy (G40.909)
- Migraines (G43.909)
Behavioral Health
- Depression (F33.9)
- Generalized Anxiety Disorder (F41.1)
- Bipolar Disorder (F31.9)
- PTSD (F43.10)
- Schizophrenia (F20.9)
Gastrointestinal / Liver
- GERD (K21.9)
- Irritable Bowel Syndrome (K58.9)
- Inflammatory Bowel Disease (Crohn’s/K50.90, Ulcerative Colitis/K51.90)
- Chronic Liver Disease/Cirrhosis (K74.60)
Renal / Urologic
- Chronic Kidney Disease (N18.9)
- Urinary Incontinence (R32)
- Benign Prostatic Hyperplasia (N40.0)
Hematologic / Oncologic
- Anemia (D64.9)
- Sickle Cell Disease (D57.1)
- Cancer (varies by type; e.g., C50.919 for breast cancer)
Infectious Diseases
- HIV/AIDS (B20)
- Chronic Hepatitis B/C (B18.1 / B18.2)
Other Chronic Conditions
- Chronic Pain Syndrome (G89.4)
- Fibromyalgia (M79.7)
- Lupus (M32.9)
How to Join the Program
You can join the CCM program by talking to your PCP, Completing the form below, or by calling ________.
Online Form
Complete the form below and our CCM team will contact you shortly.
Steps to get started
- Schedule a visit with your primary care provider to enroll OR fill out the form.
Give your consent to join the program
Begin receiving monthly check-ins and ongoing care coordination
