Chronic Care Management: What It Is and How Medicare Covers It

Chronic Care Management (CCM) is a Medicare program designed to fix exactly this problem. It pairs your parent with a dedicated care manager who coordinates their doctors, medications, benefits, and day-to-day health needs so you don't have to do it all yourself.

At Hera, we provide Chronic Care Management through dedicated geriatric social workers we call Heroes. They know your parent's full medical history, they talk to every provider, and they handle the paperwork. For roughly 90% of our clients, the cost is $0.

Here's how it works.

What Is Chronic Care Management?

Chronic Care Management is a Medicare-covered service that provides ongoing coordination for people living with two or more chronic health conditions. It was established by the Centers for Medicare and Medicaid Services (CMS) to address a straightforward problem: aging adults with multiple conditions see many different doctors and take many medications, and nobody connects the dots.

Your parent's cardiologist doesn't know what their endocrinologist prescribed last week. Their primary care doctor doesn't know they fell at home on Tuesday. Their pharmacy doesn't know that two of their medications interact. And you — the adult child trying to hold it all together from across town or across the state — spend hours on the phone trying to be the coordinator nobody asked you to be.

That's the gap Chronic Care Management fills.

How CCM Works in Practice

Under a CCM program, your parent is assigned a dedicated care manager: not a rotating call center, not a different nurse every time — a single person who knows their medical history, their medications, their doctors, and their daily situation.

That care manager:

• Reviews your parent's full medical picture across every provider

• Learns their goals and preferences around aging and care

• Communicates directly with each doctor's office to keep everyone aligned

• Monitors medication changes and flags conflicts or gaps

• Coordinates referrals, lab work, and follow-up appointments

• Serves as a single point of contact for the family

Medicare requires a minimum of 20 minutes of care management services per month for CCM billing, but in practice, a good care manager does far more than clock minutes. They build a relationship with your parent and your family. They learn the full context — not just the diagnosis codes, but the daily reality.

How CCM Differs from Other Care Models

Chronic Care Management is sometimes confused with other Medicare programs, so it helps to draw clear lines:

• Primary care visits happen in a doctor's office, typically once or twice a year. CCM happens between those visits — it's the ongoing coordination that keeps your parent's care on track.

• Home health care provides skilled nursing or therapy in the home, usually after a hospitalization. CCM is not hands-on clinical care; it's the management layer that makes sure all care is coordinated.

• Principal Care Management (PCM) is a related Medicare program focused on a single complex chronic condition. CCM covers patients with two or more conditions and provides broader coordination.

• Care coordination through a doctor's office sounds similar in theory, but most primary care practices don't have the staff or bandwidth to provide meaningful between-visit coordination. CCM programs like Hera exist specifically to fill that gap.

The simplest way to think about it: your parent's doctors provide treatment. A chronic care manager takes care of everything that happens outside of the doctor’s office — making sure that treatment is organized, consistent, and actually working.

What Conditions Qualify for Chronic Care Management?

To qualify for Chronic Care Management under Medicare, your parent must meet two criteria:

1. Two or more chronic conditions that are expected to last at least 12 months (or until end of life)

2. Original Medicare (Parts A and B) — not a Medicare Advantage plan

The chronic conditions don't need to be severe or life-threatening. They need to be ongoing and requiring active management.

Common Qualifying Conditions

The following conditions frequently qualify patients for CCM services. Your parent doesn't need to have conditions from this exact list — these are the ones we see most often:

• Hypertension (high blood pressure)

• Diabetes (Type 1 or Type 2)

• Heart disease (congestive heart failure, coronary artery disease, atrial fibrillation)

• Chronic kidney disease

• Chronic obstructive pulmonary disease (COPD)

• Arthritis (osteoarthritis, rheumatoid arthritis)

• Depression or anxiety disorders

• Alzheimer's disease and other forms of dementia

• Osteoporosis

• Hypothyroidism

• Obesity

• Chronic pain conditions

• Cancer (active or in remission with ongoing monitoring)

• Parkinson's disease

Many older adults have several of these conditions at once. A parent with diabetes and high blood pressure qualifies. A parent with arthritis, depression, and hypothyroidism qualifies. The threshold is lower than most families expect.

Medicare Advantage Patients

One important limitation: Chronic Care Management under the standard Medicare billing codes is available to patients with Original Medicare only. Medicare Advantage (Part C) plans handle care coordination differently, and most do not cover external CCM services.

If your parent has a Medicare Advantage plan and you're unsure about their options, it's still worth having a conversation. We can help you understand what's available.

Where Hera Provides CCM Services

Hera currently serves families in New York and New Jersey. Our Heroes coordinate care with providers throughout both states, whether your parent lives in Manhattan, suburban Westchester, or southern New Jersey. Because the coordination happens by phone and video, your parent doesn't need to travel anywhere for CCM services — their Hero comes to them.

Not Sure If Your Parent Qualifies?

Eligibility can feel confusing, especially when you're trying to sort through Medicare rules on your own. Hera offers a free consultation where we review your parent's conditions, verify their Medicare coverage, and tell you exactly what's covered — no obligation, no pressure.

Schedule a free consultation to find out if your parent qualifies.

What Does a Chronic Care Manager Actually Do?

The short answer: everything you've been trying to do yourself, but with clinical training (in social work, nursing, geriatrics, and palliative care), direct access to providers, and the time to do it right.

The longer answer covers the full range of what Hera's Heroes handle for families every day.

Coordinate Between All of Your Parent's Doctors

Most older adults see three to seven different specialists. Each one focuses on their own area. Nobody has the full picture — except your parent's Hero.

Your Hero maintains a complete, current understanding of every provider your parent sees, every diagnosis, every treatment plan. When one doctor makes a change, your Hero communicates that change to every other provider who needs to know. No more playing telephone. No more hoping the cardiologist's office faxed the records to the primary care doctor.

Set Up and Manage Medications

Medication management is one of the highest-impact things a care manager does. Older adults with multiple chronic conditions often take 8, 10, or 15 medications. Keeping them straight is difficult.

Hera's Heroes arrange for pre-sorted blister packs — medications organized by day and time, delivered to your parent's door, covered through their insurance. They review the full medication list for conflicts, redundancies, and gaps. When a doctor adds or changes a medication, your Hero updates the pharmacy and every other provider.

This isn't just convenient. Medication errors are one of the leading causes of emergency room visits for older adults. Proper medication management prevents hospitalizations.

Navigate Medicaid Applications and Benefits Enrollment

If your parent needs Medicaid, your Hero handles the application process. Medicaid enrollment is notoriously complex: the paperwork is dense, the requirements vary by state, and a single missing document can delay approval by months.

Your Hero knows the process, knows what each state requires, and handles the back-and-forth with the Medicaid office directly. They also identify other benefits your parent may qualify for, including programs many families never hear about.

Arrange Home Care, Transportation, and Safety Equipment

When your parent needs a home health aide, your Hero finds qualified providers and coordinates the referral. When they need reliable transportation to medical appointments, your Hero arranges it. When their doctor recommends a hospital bed, walker, or shower chair, your Hero handles the order and the insurance paperwork.

These aren't small tasks. Each one can take hours of phone calls for a family member to figure out. Your Hero already has the relationships, the knowledge, and the systems to get it done efficiently.

Handle Insurance Calls, Paperwork, and Prior Authorizations

Anyone who has spent 45 minutes on hold with an insurance company knows this pain. Prior authorizations alone — the process where insurance must approve a treatment before it's covered — can take days of follow-up.

Your Hero handles all of it. Insurance disputes, claim questions, pre-authorization requests, appeals. They know the codes, they know the processes, and they know how to get answers.

Keep the Family Updated

You shouldn't have to call five people to find out how your parent is doing. Your Hero provides regular updates to the family — what's changed, what's coming up, what needs attention. You stay informed without having to be the one managing every detail.

This is especially important for families where siblings share caregiving responsibilities, or where adult children live in a different city or state from their parent. Your Hero becomes the central source of truth.

What Families Say

Lance K., whose family works with Hera, put it this way:

"Before Hera, dealing with nurses, Medicaid, Medicare was a total mess. Now, when something comes up, our Hero just says, 'I'll handle it' and actually does it."

"I'll handle it" captures the core value of Chronic Care Management better than any clinical description. Someone detail-oriented and dedicated takes the burden off your shoulders.

How Much Does Chronic Care Management Cost?

This is usually the first question families ask, and the answer is better than most people expect.

90% of Hera Clients Pay $0

Chronic Care Management is covered under Medicare Part B. Medicare pays 80% of the approved amount for CCM services. The remaining 20% coinsurance is typically covered by one of two sources:

• Medicaid: If your parent has both Medicare and Medicaid (dual eligibility), Medicaid covers the coinsurance. Cost to you: $0.

• Medigap (Medicare Supplement Insurance): If your parent has a Medigap policy, it typically covers the 20% coinsurance. Cost to you: $0.

Between Medicaid and Medigap coverage, approximately 90% of Hera's clients pay nothing out of pocket for Chronic Care Management.

For the roughly 10% of clients who have Original Medicare without Medicaid or a Medigap policy, the monthly out-of-pocket cost is modest — typically under $20 per month based on the standard CCM reimbursement rates.

Medicare Advantage: Not Currently Covered

If your parent has a Medicare Advantage plan rather than Original Medicare, standard CCM billing does not apply. Medicare Advantage plans structure their benefits differently, and most do not reimburse external CCM providers.

If your parent has Medicare Advantage (instead of Original Medicare), we unfortunately cannot provide services at this time, but we’re working to accept Medicare Advantage plans soon.

We believe in being transparent about this. If your parent has Medicare Advantage, we'll tell you upfront during the consultation rather than letting you discover it after paperwork has been filed.

How This Compares to Private Care Management

Private geriatric care managers — professionals who provide similar coordination services outside of Medicare — typically charge $150 to $300 per hour. Monthly retainers can run $1,000 or more. These services aren't covered by insurance.

Chronic Care Management through Hera provides comparable (and in many cases broader) coordination at no cost to most families, because it's billed directly to Medicare using established billing codes.

There are instances where hiring a private geriatric care manager could still make sense, like if you need someone to attend in-person appointments with your parent, or have worked with someone for a long time that your family trusts.

But the cost different is significant: a private care manager costs thousands of dollars per year. CCM through Hera, for most families, costs nothing.

No Hidden Fees, No Contracts

Hera verifies your parent's coverage during the complimentary consultation before any services begin. We confirm exactly what Medicare will cover, whether your parent has secondary coverage for the coinsurance, and what (if anything) will come out of pocket.

There are no hidden fees. There are no long-term contracts. If your family decides CCM isn't the right fit, you can stop at any time.

Schedule a free consultation to verify your parent's coverage.

How to Get Started with Chronic Care Management

Getting started with Hera is straightforward. The process is designed to be easy for both you and your parent.

Step 1: Complimentary Consultation

Call or schedule online. We'll spend 15 to 20 minutes learning about your parent's situation: their conditions, their current providers, their Medicare coverage, and the challenges your family is facing. We'll confirm eligibility and explain exactly what CCM covers.

If your parent doesn't qualify, or if CCM isn't the right fit, we can help point you toward resources that might help.

Step 2: Clinical Assessment

If your parent qualifies, we schedule a clinical assessment — a video visit with a clinician on our team. This assessment builds a complete picture of your parent's health status, medications, providers, and care needs. It's the foundation for everything that follows.

Your parent doesn't need to leave home for this visit. The assessment happens over video, and a family member is welcome to join.

Step 3: Meet Your Hero

Your parent is matched with a dedicated geriatric social worker called a Hero. This match is based on your parent's specific needs and conditions. Our Heroes have a wide range of expertise in social work, nursing, geriatrics, and palliative care.

Your Hero will introduce themselves, learn the full picture, and begin building the relationship.

This is the person who will know your parent's situation inside and out.

Step 4: Personalized Care Plan

Your Hero creates a comprehensive care plan based on the clinical assessment, your parent's goals, and your family's priorities. This plan covers medication management, provider coordination, benefits navigation, and any referrals or services your parent needs.

The care plan isn't a static document that sits in a file. Your Hero updates it as your parent's situation changes and uses it to drive action every month.

From here, your Hero is working: coordinating with doctors, managing medications, handling paperwork, and keeping your family informed. You'll notice the difference within the first few weeks.

Talk to Hera

Ready to find out if your parent qualifies? Have questions about how CCM works?

Schedule a free consultation. We'll verify coverage and walk you through everything — no obligation.

Your parent deserves coordinated care. Your family deserves support. Schedule a free consultation with Hera to find out what Medicare covers — and let a Hero take it from here.