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Chronic Care Management

Chronic Care Management

A New Medicare Program started in 2015. Medicare beneficiaries who have two or more chronic conditions are eligible to enroll for services.

Beginning January 1, 2015, Medicare will be paying for Chronic Care Management. Over the past couple of years, we have been working to organize the care we give, in an effort to keep you healthy and out of the hospital. In addition to the services we currently provide, several new services will be added, as we implement Chronic Care Management.

Disease Management

For patients with chronic diseases like cancers and blood disorders, diabetes, hypertension and COPD, our Patient Navigators can check in regularly with you. The goal is to provide you with assistance in managing your chronic medical condition and to provide you with information so that you can manage your health. By being aware of changes in your status, we will strive to make adjustments in your care which will result in decreasing the need for an office appointment, emergency room visit or hospital admission. This will help reduce your out of pocket expenses.

Medication Management

Many patients take multiple medications, often from more than one physician. Some medications require special monitoring. Our Patient Navigators can review your medications, to make sure that they remain appropriate for your chronic conditions. Additionally, our Patient Navigators can assist in reducing the cost of your medications, particularly when your insurance company makes changes to your drug formulary. They can also connect you with patient assistance programs when needed.

Coordination of Care

The US healthcare system has become very complex. Our Patient Navigators can serve as your advocate, to help you through the healthcare system. We will work with health care providers and agencies, including specialists, hospitals, home health agencies and medical suppliers, to obtain the care that you need. We will also strive to make sure that you are receiving appropriate care, while avoiding duplicate or conflicting tests and treatments. You will receive a personalized, comprehensive plan of care for all of your health issues.

On Call

We strive to provide appointments at our office(s), to those who need one. After the office closes, the physician on call can be reached. The purpose of the on-call physician is to deal with urgent issues that arise on nights and weekends. You should call the on-call physician if you have a significant new problem, a significant worsening in your condition, or you are concerned that you may need to be seen in an emergency room or urgent care. The on-call physician does not refill medications, address issues that have been ongoing under the care of other providers, or address problems that should be evaluated in an office setting.


Medicare will only be billed for months that you are receiving at least 20 minutes of Chronic Care Management services, as described above. Fees are subject to the usual Medicare deductible and co-insurance applied to physician services. For someone on Medicare with no supplement you would be responsible for your deductible and then approximately $8.40\month when services are provided. If you have a supplement you may not incur any additional cost. Our goal would be to help you avoid a bigger cost such as an ER visit or hospital stay. You can only be signed up with one physician for this service and given your disease we recommend that your physician be your hematologist/oncologist. Please let us know if you have entered into a similar agreement with another physician.


We will still strive to give you the best care possible but work performed outside of office visits will be prioritized to those participating in our Chronic Care Management program. If you decide not to participate in the program, the following are some services you may not receive:

  1. Health concerns will have to be addressed at appointments, rather than your personal Health Coach.
  2. Care questions by family members and care givers will have to be addressed at the patient’s appointment.

If signed up for the program your family could speak to your Health Coach and have some questions answered without you having to come to the office.

Sign-Up Required

In order for us to provide you with Chronic Care Management, you need to complete the Chronic Care Management Agreement and return it to our office. Your completion of this form is required for us to bill Medicare for the services we provide you. You can also opt out of the program at any time by requesting appropriate paperwork. Your services will end at the end of the month you drop out.

If you have questions about the Medicare Chronic Care Management program please call the office to discuss with us.

For More Information

Chronic Care Management


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