Care management services
Care management services are covered under the Medicare program. This is a central location for all care management services, including links to related CMS resources and references.
These services include advanced care planning, advanced primary care management, behavioral health integration services, chronic care management and transitional care management.
Advance care planning (ACP) is a voluntary, face-to-face service between a physician or other qualified health care professional (QHP) and a patient, family member, caregiver, or surrogate to discuss the patient’s health care wishes if they become unable to make their own medical decisions.
- Advanced primary care management (APCM) services combine elements of several existing care management and communication technology-based services.
- Behavioral health integration services or BHI is a model of care incorporating behavioral health care into other care, like primary care, to improve mental, behavioral, or psychiatric health for many patients. BHI includes care management services for behavioral health conditions and may be particularly helpful for patients who aren’t improving under other models of care.
- Chronic care management services are covered by Medicare for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient.
- Transitional care management services are covered by Medicare for a patient following a discharge from a hospital, SNF, or CMHC stay, outpatient observation, or partial hospitalization.
General information regarding the Medicare program overall can be found using the topics located on the navigation bar. Please subscribe to our mailing lists to stay current with Medicare update and changes.
Advance care planning
- Advance care planning services fact sheet
- Advance care planning services FAQs
- CR9271 - Advance care planning (ACP) as an optional element of an annual wellness visit (AWV)
- CR10000 - Billing for advanced care planning claims
- 42 Code of Federal Regulations, Part 489, subpart 1 (policy governing advanced directives)
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 18, section 140.8
Advanced primary care management
Behavioral health integration
- Behavioral health integration services booklet
- Behavioral health integration FAQs
- Behavioral health services
Chronic care management
- Chronic care management services fact sheet
- CMS identifies 15 chronic conditions for Medicare
- Chronic conditions data warehouse
- Chronic care management frequently asked questions
- Chronic care management and patient communication
- MLN909188 - Chronic care management (cms.gov)
- MLN Matters article, MM11560 - Calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule - Comprehensive care plan
Transitional care management
- MLN Matters article, MM11560 - Calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule - Transitional care management
- Transitional care management services fact sheet