Since last October, Medicare pays a health center for the month of care between visits as its own codes, at national amounts, on top of every visit. At a safety-net center where much of the Medicare panel is dually eligible, the top monthly advanced-care code is worth more here than at most practices. The Medicare book is small today and fills inside the first quarter, and it grows as the health center does, with no capital and no new hires. The people to run it are ours. This is the 24-month plan, inside eClinicalWorks, with CoachCare staffing the program.
Two counts, two jobs. 44 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 68 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $63,092 of the $148,752 is the health center's after CoachCare's fees.
A federally qualified health center that grew from a volunteer clinic, started by an Atlanta head-and-neck surgeon who kept seeing disease caught too late in the neighborhoods the system missed, into a six-site center serving 2,330 patients a year across southwest Atlanta and Douglas County. Primary care, women's health, behavioral health, dental and telehealth, on eClinicalWorks, with 340B behind the pharmacy. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 2,330 patients in its 2024 federal filing, 98% from communities of color and more than nine in ten below the federal poverty line. A section 330 federally qualified health center, built for exactly the patients hardest to reach between visits.
At a safety-net center, a large share of the Medicare panel is also on Medicaid. That is what puts the top advanced primary care management tier, G0558 at $117.24 a month, in reach for much of the panel, and it is why the monthly code is worth more here than at most practices.
A main campus on Cascade Road, a Douglasville clinic, a dental site, two school-based sites and a mobile medical unit, with telehealth live at every one. A health center that already reaches patients outside the exam room is the right one to be paid for the month between visits.
340B has been active since 2015, and the whole center runs on eClinicalWorks with a patient portal. The chart, the pharmacy and the billing engine a monthly program needs are already in place. Nothing new has to be bought to start.
One structural fact completes the picture: no remote patient monitoring, chronic care management or advanced primary care management program is visible at the health center today, in its claims record or on its careers page. The chronic-disease burden in this panel is high and documented. The registries live in eClinicalWorks. The patients are seen a few times a year, and between those visits there is no revenue line yet.
Three things changed for a health center inside a year: how care management is billed, what remote monitoring can bill for, and what a dual-eligible panel is worth on the monthly code.
Through September 2025, a health center billed care management as one bundled code, G0511. Since October 2025, a health center bills chronic care management, remote monitoring and advanced primary care management as individual codes at the national non-facility amounts, in addition to the PPS encounter for the visit. Each service is paid on its own, every month it is delivered. The figures on this page are priced at the national amounts a health center is paid for these codes.
New 2026 codes for 2 to 15 days of device data and for the first 10 minutes of management remove the 16-day floor that used to block episodic monitoring. A patient home from a hospital stay can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $14,277 of reimbursement over 24 months before denials and bad debt, about 9.6% of net reimbursement.
Advanced primary care management pays a flat monthly amount by tier: $16.37, $53.78 and, for a patient who is a Qualified Medicare Beneficiary, $117.24. Because so much of a safety-net Medicare panel is dually eligible, the tier mix on this forecast blends to $68.12 per patient-month, and G0558 is the single best-paying monthly code on the page. The enrollment and engagement labor that earns it is CoachCare's.
A named service line with its own P&L and scorecard, following the Medicare patients the health center already knows, inside the eClinicalWorks chart it already runs. Remote monitoring for the conditions that produce readings, chronic care management for patients with two or more conditions, and advanced primary care management where the dual-eligible mix makes it the better monthly code.
| Service | Codes | CY2026, national non-facility | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $21.71 setup · $52.11/mo | Hypertension and diabetes cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.77 + $41.42 add'l · $26.05 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $66.13 + $50.44 add'l | Two or more chronic conditions; the longitudinal wrapper |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.37 · $53.78 · $117.24/mo | The primary-care panel by complexity tier; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | $220.11 / $298.60 per discharge | Discharges from Atlanta-area hospitals; not in the forecast below |
| Behavioral health integration | 99484 | $57.45/mo | The next arm; not in the forecast below |
Amounts are the CY2026 Medicare physician fee schedule national non-facility rates, the rail a health center bills the care-management codes on in addition to the PPS encounter, and the basis every figure on this page is priced on.
A 24-month forecast for the RPM + CCM + APCM stack: an estimated 150 Medicare patients, all of them in scope from month one, the health center's adult-medicine clinicians plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the eClinicalWorks integration. The panel size is the health center's own count of Medicare patients by payer, and confirming it is the first working-session item; the Scenario Explorer lets you plug in the real number. Transitional care and behavioral health integration are named but not in these figures, and no Medicaid dollar is.
After denials and coinsurance bad debt; $72,144 in Year 1 and $76,608 in Year 2.
42.41% of net reimbursement after CoachCare's fees: 37.49% in Year 1, 47.05% in Year 2.
Unique patients in active remote care at month 24, the same count as at month 12, because the panel is full by month 3.
RPM 34 + CCM 18 + APCM 16 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $76,168 | $38,679 | $37,489 |
| CCM | $46,676 | $20,988 | $25,687 |
| APCM | $25,909 | $13,050 | $12,860 |
| Implementation, eClinicalWorks integration, outreach | — | $12,944 | −$12,944 |
| 24-month total | $148,752 | $85,661 | $63,092 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the health center and never deducted from its margin. | |||
| Year | Net reimb. | CoachCare fees | Net to health center | Margin |
|---|---|---|---|---|
| Year 1 | $72,144 | $45,098 | $27,046 | 37.49% |
| Year 2 | $76,608 | $40,563 | $36,046 | 47.05% |
| 24 months | $148,752 | $85,661 | $63,092 | 42.41% |
Recurring care-management and monitoring volume over 24 months, filed by the health center's own billing team.
Blood pressure, weight and glucose, a continuous picture of the hypertension and diabetes cohorts between visits.
About $78,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 995 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 16 enrollments in month 2, CCM its ceiling of 18 in month 2, and RPM its ceiling of 34 in month 3. From there the census holds at 68 program enrollments, 44 patients; month 12 and month 24 are the same number. The binding constraint on this forecast is the size of the Medicare panel, not enrollment capacity and not clinician count. The first 90 days, modeled: 30 new enrollments in month 1, 25 in month 2, 15 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 34 | 150 in scope × 65% eligible (98) × 35% acceptance | Month 3 |
| CCM | 18 | 150 × 40% (60) × 30% | Month 2 |
| APCM | 16 | 150 × 35% (52) × 30% | Month 2 |
| At month 24 | 68 | Program enrollments = 44 patients | — |
Every ceiling above is reached with CoachCare's own enrollment support, funded by CoachCare and sized to the panel. Without it the same ceilings are reached in months 8, 6 and 4 instead of 3, 2 and 2, and 24-month net reimbursement falls to $133,252. It cannot raise a ceiling. Reaching it months sooner is worth $15,500 over 24 months, and it is CoachCare's payroll, not the health center's.
Because every program fills inside the first quarter, the number that moves this forecast is the size of the Medicare panel itself, and today that panel is small and estimated. The health center's own count of Medicare patients by payer is the first working-session item, and the model re-runs on it in minutes. The same program on 170 Medicare patients is $167,775 of 24-month net reimbursement; on 210 it is $204,663. The second lever is time: as the health center's Medicare panel grows, the line grows with it, while the Medicaid and uninsured majority is where the clinical reach compounds.
The health center runs on eClinicalWorks, and this plan is priced on CoachCare's eClinicalWorks integration. Enrollment flags and orders are placed inside the eClinicalWorks workflow; monitored vitals, Evidence of Care documents, care plans and enrollment status post to the chart every month; claims are created automatically in eClinicalWorks billing; and the health center's own billing team files them with the care-management codes.
A physician, PA or NP flags an eligible patient and places the order inside eClinicalWorks, the way a lab order is placed. CoachCare picks it up, ships the device and reaches the patient.
Readings, calls and care-plan work happen on CoachCare's platform and care team, with the escalation pathway below routing anything that needs a clinician.
Every month, vitals, the Evidence of Care document, the care plan and the patient's enrollment status post to the eClinicalWorks chart. One chart, no second system for clinicians.
Claims are created automatically in eClinicalWorks billing with the care-management codes on them, and the health center's own billing team files them. No PDFs, no re-keying.
The health center's clinicians set the thresholds and own every clinical decision. CoachCare's care team works the readings and the calls between visits and routes each finding one of three ways. The thirty days after a hospital discharge get a fixed three-touch cadence, because that is where an admission repeats.
Any hospitalization or observation stay in the last 60 days triggers three touches inside two weeks. It is also the TCM episode: contact within two business days, the visit within 7 or 14 days, and a device in the home before the first follow-up.
Reach the patient, reconcile medications against the discharge instructions, confirm the device is transmitting.
Symptom and reading review, barriers to the plan, follow-up appointment confirmed with the clinic.
Close the episode or extend it; anything trending is escalated through the engine below.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. CoachCare's urgent and emergent policy supersedes any client-specific preference, on any day. If the patient refuses, the clinic is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse the health center designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a symptom check that is clean closes the loop with a chart note and nothing else. The clinic's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a set cadence, the clinic is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
A remote care program for a safety-net panel is not the one that works in a suburb of retirees. Most of these patients are low-income, many are managing more than one chronic condition, and the barriers between visits are as often social as clinical. Six design decisions follow from that.
Every cuff, scale and glucometer ships with its own cellular connection and transmits on its own. No smartphone, no home internet, no app to install, no account to set up. The device works the day it comes out of the box, which matters most for the patients hardest to reach online.
Instructions and call scripts written at a low reading level, in the languages the health center serves, delivered by phone rather than through a portal. A monthly documented call reaches people a patient-portal login and an office calendar do not.
The health center already screens for food, housing and transportation. A structured monthly touch is where a skipped medication, a transport problem or a lapse in coverage shows up between visits, in time to route it to the team that can act on it.
Consent, device setup and the first reading happen face to face, at the clinic, at the Douglasville site and on the mobile unit, on the day a patient is already in for care. CoachCare's enrollment support does the work, on CoachCare's payroll.
Lists come from the chronic-disease registries in eClinicalWorks first, then by payer, so the Medicare-billable patients are worked first while the rest are queued for the clinical program. The registries already exist; the program puts a monthly touch on them.
The adult-medicine roster runs on a family physician and a nurse practitioner. The care-management codes are written for general supervision, so the team as it stands today fits the way the codes work, without adding clinical headcount.
The health center serves southwest Atlanta and Douglas County from a main campus on Cascade Road, a Douglasville clinic, school-based sites and a mobile medical unit. It is one of metro Atlanta's safety-net anchors for a population that is low-income, largely uninsured or on Medicaid, and carrying more chronic disease than its size suggests.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, repriced at the national amounts a health center is paid, the same basis the forecast itself uses.
The proposals reach the remote-monitoring family only. Chronic care management and advanced primary care management are not in them, and on this forecast those two carry $72,585 of the $148,752 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $1,157 of the $8,409 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an arrangement in which CoachCare manages the staffing while the health center owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS is moving remote care toward payment for results: per-member-per-month amounts with a share withheld and reconciled against outcomes. Fee-for-service code cuts and that shift are the same policy argument. A health center with a consented, documented, monthly-managed panel and continuous readings is what every version of that payment rewards, and this service line builds that panel under fee-for-service first.
Three numbers, each smaller than the last, because each one sits on a larger base. Both bars are drawn on one shared dollar scale, so the orange can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at the national non-facility amounts on this forecast's own billing mix and APCM tier weights. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B. A health center bills the care-management codes on this rail, so the table and the repricing above sit on the same basis and reconcile to the dollar.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $21.71 | $20.03 | −7.7% |
| 99445 | Device supply, 2–15 days | $52.11 | $41.38 | −20.6% |
| 99454 | Device supply, 16–30 days | $52.11 | $41.38 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $51.77 | $49.59 | −4.2% |
| 99458 | Treatment management, each additional 20 minutes | $41.42 | $40.39 | −2.5% |
| 99470 | Treatment management, first 10 minutes | $26.05 | $20.69 | −20.6% |
| Not in scope: care management | ||||
| 99490 | Chronic care management, first 20 minutes | $66.13 | $64.04 | −3.2% |
| 99439 | Chronic care management, each additional 20 minutes | $50.44 | $49.92 | −1.0% |
| G0556 | Advanced primary care management, level 1 | $16.37 | $16.09 | −1.7% |
| G0557 | Advanced primary care management, level 2 | $53.78 | $53.20 | −1.1% |
| G0558 | Advanced primary care management, level 3 | $117.24 | $116.91 | −0.3% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than the year after.
The comment period on CMS-1848-P closed September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
CoachCare operates as the service line's engine while the health center's physicians, physician assistants and nurse practitioners govern protocols and every clinical decision. Launch needs no new health-center headcount and no capital; the eClinicalWorks integration runs in parallel with onboarding, and the first enrollments follow the first orders.
eClinicalWorks integration scoped and started; named program lead at the health center; P&L and scorecard; claim configuration with the billing team; protocol sign-off for the hypertension and diabetes pathways; the discharge trigger wired to the three-touch cadence.
APCM across the dual-eligible panel, CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts; CoachCare's enrollment support working the clinic and the mobile unit; the post-discharge cadence live from day one.
APCM fills in month 2, CCM in month 2, RPM in month 3; a monthly scorecard to leadership, feeding the chronic-disease measures the health center reports each year to HRSA.
Re-run eligibility against the payer reconciliation, widen the cohorts as the Medicare panel grows, bring transitional care to every discharge, and add behavioral health integration as the next arm alongside the health center's own behavioral-health team.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
10,000+ providers running remote care programs day to day.
1,000+ programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded; 4 million+ care actions enabled.
The service line is the health center's, under its own credentials and its own billing. CoachCare is the vertically integrated engine underneath it, and the fit for a lean safety-net center is the point.
The devices, the cellular connectivity, the logistics, the software platform and the care team are one stack from one partner, not a patchwork stitched together. For a panel where home internet and smartphones cannot be assumed, cellular devices that work out of the box are what makes enrollment stick.
Enrollment flags, monitored vitals, care plans, the Evidence of Care document and the claim all live in the eClinicalWorks chart the health center already runs. Clinicians stay in one system; the health center's own billing team files the claims under its own credentials.
Enrollment, care management and device logistics are CoachCare's payroll, embedded in the fee and never deducted from the health center's margin. A full-service model designed so a mission-driven center adds a margin-positive line without adding cost or clinical staff.