Chronic Care Management Plan: What It Is, Requirements, and Best Practices

Chronic diseases account for roughly 90% of the nation’s healthcare expenditures and are the leading causes of death and disability in the United States. And the number of people living with chronic illness is expected to double from 2020 to 2050. 

With these statistics in mind, managing patients with chronic conditions demands a proactive, ongoing approach to care that addresses their complex needs. The traditional fee-for-service model, where providers are paid for each specific service, is not cutting it, especially for delivering this level of support.  

Instead, a chronic care management (CCM) plan provides a structured value-based framework to improve patient outcomes while creating a sustainable revenue stream for your practice. 

If you are a provider looking to implement or refine your CCM services, understanding the nuts and bolts of a compliant plan is essential. This article will walk you through what a CCM plan is and its requirements, who it benefits, and the best practices for implementing one in your practice.  

What Is a Chronic Care Management Plan? 

A chronic care management plan, often through Medicare, is a comprehensive, patient-centered care plan that outlines the treatment and management of a patient’s chronic conditions.  

It serves as a roadmap for the patient, their caregivers, and the entire care team. The core of a CCM plan is proactive, ongoing care coordination outside of regular office visits. 

A CCM plan looks something like this: 

• You and your patient work together to outline their health problems and goals, the other specialists involved in their care, their medications, and other information about their care needs. 

• After creating the outline, you’ll have the patient sign a consent form for them to receive this set of services on a monthly basis.  

• Next, you’ll prepare a care plan for the patient that explains the care needed and how you’ll coordinate it. 

Unlike a general care plan, which might be created for a specific episode of care, a CCM plan is a living document. It includes long-term health goals, continuous monitoring, and coordinated communication between all providers involved in the patient’s health.  

It shifts the focus from “sick care”—treating problems as they arise—to “well care,” where the goal is stability and prevention. This shift from reactive to preventive care helps manage conditions more effectively and keeps patients healthier. 

RELATED CONTENT: What is Chronic Care Management? 

Who Needs a Chronic Care Management Plan? 

Not every patient requires CCM services. These plans tend to be for a subset of your patient population who need extra support to stay healthy and out of the hospital. 

According to the Centers for Medicare and Medicaid Services (CMS), the primary candidates for a chronic care management plan are Medicare-eligible patients with two or more chronic conditions expected to last at least 12 months. These conditions place the patient at significant risk of functional decline or death. 

Common conditions that qualify for CCM services include: 

• Diabetes 

• Hypertension (high blood pressure) 

• Chronic Obstructive Pulmonary Disease (COPD) 

• Congestive Heart Failure (CHF) 

• Alzheimer’s disease and related dementia 

• Cancer 

• Cardiovascular disease 

What Are the CMS Requirements for a Chronic Care Management Plan? 

CMS has specific requirements to ensure patients receive the best coordinated care. Adhering to these standards is essential for compliance and reimbursement. 

• Patient Consent: You must obtain and document the patient’s verbal or written consent before providing or billing for CCM services. This conversation should explain what CCM is and that cost-sharing applies. 

• 24/7 Access: Patients must have 24/7 access to a physician or other qualified healthcare professional who can address urgent needs. You don’t have to be on call at all hours, but a system must be in place. 

• Comprehensive Care Plan: The CMS chronic care management plan must be documented in the patient’s medical record. It must be a comprehensive, patient-centered plan based on a physical, mental, cognitive, and environmental assessment. 

• Care Coordination: Your team is responsible for managing transitions of care, coordinating with other providers, and ensuring all parties are aligned on the patient’s treatment. 

• Documentation Standards: Every interaction, whether by phone, email, or prescription refill, must be documented in the EHR to justify the time billed. 

Key Components of an Effective Chronic Care Management Plan 

To build CCM services that truly work, you need a clear plan for the patient’s health journey. According to CMS, it should contain the following key components to guide the care process effectively. 

Patient Health Information and Diagnoses 

Start with the basics, but make them comprehensive. This section should include a full list of chronic conditions, current medications, allergies, and relevant medical history. It sets the baseline for all future decisions. 

Care Team Roles and Responsibilities 

Clearly define who is doing what. Who’s the primary clinician? Who’s the care manager responsible for monthly check-ins? What is their contact information? Listing these roles ensures accountability and helps the patient know exactly who to contact for different needs. 

Treatment Goals and Outcomes 

In collaboration with the patient, establish measurable, realistic health goals. These could be related to blood pressure targets, A1c levels, or weight management. A patient-centered care plan for chronic conditions empowers individuals by making them active participants in their health journey. 

Medication Management 

Another component of an effective CCM plan is a detailed medication list that includes dosage, frequency, and the reason for each prescription. This program should also include comparing this list with current medication orders to identify and resolve any discrepancies, preventing adverse drug events, and ensuring adherence. 

Care Coordination and Referrals 

Document all providers involved in the patient’s care. This includes specialists, therapists, and community-based services. The plan should outline how information will be shared among them to ensure nothing falls through the cracks during care transitions.  

Patient Engagement and Communication Plan 

Specify how and when the care team will communicate with the patient. Will it be through monthly check-in calls, a patient portal, or another method? The patient needs to feel supported and connected between office visits. 

RELATED CONTENT: What Are the Key Goals of Chronic Care Management? 

 Chronic Care Management Plan Example 

While every plan is unique, a chronic care management plan template typically follows a common structure. A provider might use their electronic health record (EHR) to build a plan that includes: 

• Patient Snapshot: Name, DOB, Medicare ID 

• Problem List: All active diagnoses (e.g., Type 2 Diabetes, hypertension) 

• Patient-Centered Goals: Lower A1c from 8.5% to 7.5% in 6 months; check blood pressure daily 

• Interventions: Monthly CCM call (phone/telemedicine) to review blood sugar records; dietary counseling referral 

• Medication List: Januvia 100mg daily, Toprol-XL 25mg daily 

• Care Team: PCP, RN (Care Coordinator), endocrinologist 

• Patient Consent: Documented on [Date] 

This organized format makes the plan easy for the entire care team to access and update. And remember, this template isn’t static; it prompts the provider to update each goal’s status at every monthly check-in.  

Benefits of Chronic Care Management Plans for Providers and Patients 

Implementing a CCM program offers significant advantages for both your practice and your patients. 

For patients, benefits include: 

• Improved health outcomes: Continuous oversight helps manage chronic conditions, leading to better health and a higher quality of life. 

• Reduced hospitalizations: Catching issues earlier prevents emergency visits. 

• Better engagement: Patients feel more connected to their care team and empowered to manage their health. 

For providers, benefits include: 

• Stronger patient relationships: Regular contact builds trust and loyalty. 

• Predictable recurring revenue: CCM provides a consistent monthly revenue stream outside of office visits, improving financial stability. 

• Enhanced care quality: A structured chronic care management workflow improves team efficiency and ensures nothing falls through the cracks. 

Chronic Care Management Billing & Medicare Guidelines 

Understanding the CPT codes is crucial for successful reimbursement. According to the American Academy of Family Physicians (AAFP), CMS has established several codes for CCM, each tied to the amount of clinical staff time spent per calendar month. A few examples include: 

• CPT Code 99490: For the first 20 minutes of clinical staff time. Average reimbursement is $60.49. 

• CPT Code 99439: An add-on code for each additional 20 minutes of time (billed with 99490). Average reimbursement is $45.93. 

• CPT Code 99487: For complex CCM, covering the first 60 minutes of clinical staff time. Average reimbursement is $70.52. 

You must meet the minimum time threshold (e.g., 20 full minutes for 99490) to bill. This time includes non-face-to-face activities such as reviewing labs, coordinating with specialists, and speaking with patients by phone. 

Common Billing Mistakes: 

• Rounding up: Never round up minutes. If you spent 18 minutes, you cannot bill 99490. 

• Double dipping: You typically cannot bill for CCM services if you are billing for other care management services in the same period. 

• Lack of consent: Billing without documented patient consent is a major compliance risk. 

Bottom line: Accurate time-tracking and adherence to the Medicare chronic care management plan guidelines are non-negotiable. 

How Technology Simplifies Chronic Care Management Planning 

Managing a CCM program manually is a heavy administrative lift. Technology, particularly an integrated EHR, is a scalable way to handle the complexity. 

• EHR-integrated care plans: Modern systems allow you to build, manage, and update the EHR chronic care management plan directly within the patient’s chart. This eliminates duplicate data entry and keeps all information in one place.  

• Automated documentation and tracking: The right care management software can automatically track time spent on calls and other CCM activities, simplifying the billing process and ensuring accuracy. 

• Secure patient communication: Integrated patient portals provide a secure channel for communication, allowing patients to ask questions and receive support between visits. 

• Reporting for compliance: Technology helps generate reports to monitor program performance, track outcomes, and ensure compliance with all CMS audit requirements. 

The iSalus all-in-one EHR can be a powerful ally in meeting all CCM planning needs. The platform centralizes patient data and offers an interactive summary that displays vitals, labs, meds, history, consent forms, and more on a single screen, providing quick insights for care planning.  

It integrates data flows, enabling care teams to communicate and coordinate effectively and improving outcomes. Other features include: 

• Automated workflows streamline tasks such as e-prescribing, appointment scheduling, and billing.  

• Tailored templates for chronic conditions (that can be customized) ensure all critical data is captured efficiently, meeting CMS guidelines. 

• A secure, HIPAA-compliant patient portal allows 24/7 access to health information, fostering better collaboration and adherence to treatment plans. It also, offers a mobile app so providers can update CCM plans on the go. 

• AI-driven analytics identify at-risk patients early, shifting care from reactive to preventive. For example, AI-powered software that analyzes EHR patient data can help predict future health risks, flagging issues like sepsis hours or days earlier, allowing for timely interventions. 

• Integrated billing, automated claims, and remittance processing ensure proper reimbursement for CCM services. The software also automatically tracks time spent on calls and other CCM activities, ensuring billing accuracy.  

Best Practices for Implementing a Chronic Care Management Plan 

A successful CCM program is built on a solid foundation. Follow these best practices to set your practice up for success. 

Start with standardized templates: Use a chronic care management plan template to ensure consistency and efficiency. Customize it for each patient but start with a proven structure.  

Train staff on CCM workflows: Your entire team needs to understand their roles and the specific chronic care management workflow. Proper training reduces errors and improves efficiency. 

Use technology to reduce admin burden: Leverage your EHR and other care management software to automate time-tracking, documentation, and patient communication. 

Review plans regularly: A CCM plan is not a “set it and forget it” document; it’s a living one. Review and update it at least annually or whenever the patient’s condition changes. 

Getting Started with Chronic Care Management 

CCM is a powerful tool for improving patient care and strengthening your practice’s financial health. By creating a comprehensive, patient-centered plan, you can provide the proactive support your patients with chronic conditions need.  

A well-designed program, supported by the right technology, makes this process manageable and scalable. 

Key Takeaways 

• A chronic care management plan provides proactive, patient-centered support for those with multiple chronic conditions. 

• CMS has specific requirements for consent, care coordination, documentation, and 24/7 access that must be met for compliance and billing. 

• A well-structured CCM plan improves outcomes, boosts patient engagement, and provides predictable revenue for your practice. 

• Using EHR-integrated care management software streamlines workflows, documentation, and communication, making CCM easier to implement and scale. 

Ready to launch a CCM program? Here are a few ways to start: 

• Identify Medicare Part B patients with two or more chronic conditions expected to last at least 12 months. Prioritize patients at the highest risk of hospitalization or who have recently been/are regularly seen in the emergency room.  

• Start training your team on the requirements for the chronic care management plan.  

• Evaluate how your current technology stack can support this new workflow. 

Need help? The iSalus all-in-one EHR can work as an extension of your care team. 

Providers and other team members can access all the data they need in one place and quickly view a graph of a patient’s vitals, medications, lab results, and more on a single screen. 

Contact iSalus today to learn how our EHR simplifies chronic care management, improves health outcomes, keeps patients engaged, and drives a new revenue stream!  

Frequently Asked Questions 

Which patients qualify for a chronic care management plan?
Patients must have at least two chronic conditions expected to last 12 months or longer that place them at significant risk of decline or death. Eligibility is most common among Medicare beneficiaries with conditions such as diabetes, heart failure, and hypertension. 

What documentation is required for compliance?
Providers must maintain comprehensive care plan documentation, detailed records of communications, time spent on non-face-to-face care, medication lists, care coordination efforts, and proof of patient consent. This ensures compliance with CMS chronic care management plan requirements. 

How does software or EHR chronic care management help providers?
Technology streamlines the CCM workflow, automates tracking and documentation, supports secure communication, and simplifies compliance reporting. Integrated EHRs prevent duplication and help practices scale their programs efficiently. 

Is there a template or example I can follow to get started?
Many EHRs and software platforms, such as iSalus, offer templates for chronic care management plans that can be customized for each patient. These templates include all required components, making it easier to meet CMS guidelines.