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Medical Services

Chronic Care Management

The Chronic Care Management (CCM) program is a new program that is covered by your Medicare Part B insurance. CCM services is provided to you by your physician and team members on a monthly basis to assist you in managing your health. Your physician’s team includes your physician, a nurse care navigator, and other support staff as needed (ie.: social worker, physical therapist, etc.) Your primary contact will be your nurse care navigator.

To qualify for CCM services you must have at least two or more chronic conditions expected to persist at least 12 months that place you at significant risk of becoming worse.

You will be required to sign a consent to participate in the services, which will be explained to you fully prior to your services starting. You may cancel the service (effective at the end of the calendar month) at any time. You may only receive the CCM service from one physician at a time.

Services include:

  • In conjunction with you, we will develop a comprehensive care plan that is regularly reviewed with you and update it as your condition(s) changes.
  • We will provide a minimum of 20 minutes of service per month.
  • You will have 24/7 access to care team member via phone and/or electronic communication.
  • Regular communication by your health care
  • manager to you via telephone, email, or your patient portal. You decide!
  • Medication reconciliation and monitoring.
  • Management of care transitions from one level of care to another.
  • Referrals to other appropriate healthcare and community services as needed.
  • Reminders and assistance in scheduling of regularly scheduled appointments, including annual wellness visit, routine screening and follow-up appointments.

Talk to your provider today to see if you qualify for this new Medicare benefit.