Medically reviewed by Dr. Rajan Kohli, MD, board-certified Family Medicine — Lakewood Primary Care and Wellness, Dallas.
This article is for general education and is not a substitute for personalized medical advice. A consultation determines what is right for you. Medicare rules change; for official, plan-specific coverage details visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
If you live with high blood pressure, diabetes, heart disease, COPD, arthritis, or another long-term condition, you already know that your health doesn’t pause between appointments. Medications need adjusting, lab results need follow-up, specialists need to talk to each other, and questions come up at inconvenient times. Medicare recognizes this. Through a benefit called Chronic Care Management (CCM), Original Medicare Part B covers structured, ongoing support from your primary care team in the weeks between office visits.
Many Medicare patients in Dallas, from Lakewood and East Dallas to Lake Highlands, Preston Hollow, and the Park Cities, have never heard of CCM, even though they may qualify. Here’s how it works.
What is Medicare chronic care management?
Chronic care management is a Medicare-covered service for people managing two or more chronic conditions. Instead of limiting care to the 15 or 20 minutes you spend in the exam room, CCM pays for the coordination work that happens outside the visit. That includes reviewing your medications, following up on test results, coordinating with your cardiologist or endocrinologist, helping with transitions after a hospital stay or ER visit, and checking in on how your treatment plan is working.
CCM is built around a comprehensive care plan, a written document you and your care team create together. According to the Centers for Medicare & Medicaid Services (CMS), that plan typically covers a problem list, measurable treatment goals, expected outcomes, symptom management, medication management, planned interventions, coordination with outside practitioners and community resources, and periodic review. You get a copy, and the plan is revised as your health changes.
Who qualifies for CCM under Medicare?
Under CMS guidelines, you may be eligible if you have:
- Two or more chronic conditions expected to last at least 12 months (or for the rest of your life), and
- Conditions that place you at significant risk of death, acute flare-ups or decompensation, or functional decline.
Common examples include hypertension, type 2 diabetes, high cholesterol, coronary artery disease, heart failure, chronic kidney disease, COPD or asthma, osteoarthritis, depression, hypothyroidism, and osteoporosis. Many people over 65 have two or more of these at once. Whether CCM is appropriate for you is a clinical decision your physician makes with you; a consultation determines whether it fits your situation.
What CCM looks like day to day
Most CCM work is “non-face-to-face,” meaning it happens by phone, secure patient portal message, or other electronic communication rather than an in-person visit. Medicare structures CCM around monthly blocks of care time. For example, the standard CCM service covers at least 20 minutes of clinical staff time per calendar month directed by your physician, with additional time billed in further increments when your needs are more involved. Physician-provided CCM and “complex” CCM (for patients whose care plans need substantial revision) use longer time thresholds.
In practice, a month of CCM might include:
- A check-in call to review home blood pressure or blood sugar readings
- Reconciling medications after a specialist adds a new prescription
- Making sure a referral was received and an appointment scheduled
- Following up after an urgent care, ER, or hospital visit
- Answering questions about side effects or symptoms before they become emergencies
- Updating your care plan as goals are met or conditions change
CMS also requires CCM programs to give patients a way to reach the care team about urgent needs and to keep a consistent, designated care team member involved in their care, so you’re not starting from scratch every time you call.
Consent: what you’ll be told before you start
CCM is voluntary. Before a practice can begin and bill for CCM, Medicare requires that you give consent, either verbally or in writing, and that the consent is documented in your record. As part of that conversation, you should be told:
- That cost sharing may apply (see below)
- That only one practitioner can provide and bill CCM for you in a given calendar month, so if another doctor already provides CCM, you’d choose one
- That you can stop CCM at any time, effective at the end of that calendar month
What does CCM cost with Medicare?
Under Original Medicare, CCM is a Part B service, so the Part B deductible and the standard 20% coinsurance generally apply. For 2026, CMS set the Part B deductible at $283 for the year. If you have a Medigap (Medicare Supplement) policy, it may cover some or all of your share. If you’re enrolled in a Medicare Advantage plan, your costs depend on your specific plan. Check your plan documents or call the number on your card. For official coverage information, visit Medicare.gov or call 1-800-MEDICARE.
Some patients who qualify for the Qualified Medicare Beneficiary (QMB) program have little or no cost sharing for Part B services. Medicare.gov explains how those programs work.
CCM vs. Advanced Primary Care Management (APCM)
Starting in 2025, Medicare added a newer option called Advanced Primary Care Management (APCM). APCM bundles elements of care management and communication services into a single monthly service that doesn’t depend on counting minutes, with levels based on how many chronic conditions a patient has. You don’t need to choose between these yourself. If ongoing care management makes sense for you, your physician’s team can explain which approach applies. The practical goal is the same: continuous, coordinated primary care rather than isolated visits.
Why ongoing care matters for chronic conditions
Chronic conditions tend to interact. Kidney function affects which diabetes medications are safe; blood pressure goals shift with heart and kidney disease; new prescriptions from one specialist can affect another condition. A primary care physician who sees the whole picture and has a structured way to follow up between visits can catch problems earlier: a rising A1c, a medication interaction, a missed referral. Outcomes vary from person to person, and no program guarantees results, but coordinated care helps keep the moving pieces from falling through the cracks.
CCM also pairs naturally with services you may already use, such as your Medicare Annual Wellness Visit, which focuses on prevention and a personalized prevention plan, while CCM supports the day-to-day management of established conditions.
Medicare primary care in Dallas at Lakewood Primary Care and Wellness
Lakewood Primary Care and Wellness is a physician-led practice in North Dallas, near Walnut Hill Lane, serving patients from Lakewood, East Dallas, Highland Park, University Park, Preston Hollow, Lake Highlands, Uptown, and across DFW. We accept Medicare and are accepting new Medicare patients. Dr. Rajan Kohli, MD, is board-certified in Family Medicine with more than 20 years of experience and is on staff at Texas Health Presbyterian Hospital Dallas.
If you’re managing several chronic conditions, we can review your history, medications, and goals and talk through whether chronic care management or other care-coordination options make sense for you.
Frequently asked questions
Does Medicare cover chronic care management?
Yes. Original Medicare Part B covers chronic care management for eligible patients with two or more chronic conditions expected to last at least 12 months that put them at significant risk. The Part B deductible and coinsurance generally apply. Medicare Advantage costs depend on your plan.
Do I have to come into the office for CCM?
Most CCM services happen between visits by phone, patient portal, or other secure communication. You’ll still have regular office visits as your conditions require; CCM adds structured support in between.
Can I have CCM with more than one doctor?
No. Medicare allows only one practitioner to provide and bill CCM for you in a calendar month. Many patients choose their primary care physician because that’s where their overall care is coordinated.
Can I stop chronic care management?
Yes. CCM is voluntary, and you can stop at any time. The change takes effect at the end of the calendar month.
Which conditions count as “chronic” for CCM?
Conditions expected to last a year or longer, such as hypertension, diabetes, heart disease, COPD, chronic kidney disease, arthritis, depression, or thyroid disease, can count. Your physician determines whether your combination of conditions meets Medicare’s criteria.
Ready to get more consistent support for your chronic conditions? Request an appointment online or call 214-810-4331. New patients welcome. Lakewood Primary Care and Wellness, 8210 Walnut Hill Lane, Professional 1, Suite 516, Dallas, TX 75231.
