Since October 2025, Medicare pays a rural health clinic for each month of chronic care management, remote monitoring and advanced primary care management as its own codes, at national amounts, on top of the visit. On the clinic's 600 Medicare patients that is $508,687 of net reimbursement over 24 months and $217,586 net to the clinic. The clinic already has the panel, the eClinicalWorks workflow and the clinical reason. CoachCare supplies the enrollment and the monthly work.
Two counts, two jobs. The headline is 177 unique patients at month 24. The enrollment chart and the Scenario Explorer show 271 active program enrollments, because a patient on remote monitoring and a care-management program is one patient with two enrollments.
Advanced Family Medical Center has been a certified Rural Health Clinic since November 2019, in a county the federal government designates as short of primary care. It takes same-day appointments and walk-ins, runs its own labs and X-ray, and keeps a sliding-fee scale so cost does not turn anyone away. It already bills chronic care management for its Medicare patients inside eClinicalWorks, and it already belongs to a Medicare Shared Savings Program ACO that moved to the two-sided track this year. Its clinical focus is hypertension and diabetes, the two conditions remote monitoring handles best.
Independent and freestanding, certified since November 2019, with its own Rural Health Clinic shortage designation inside a county-wide primary-care shortage area. That certification is what puts the CY2026 care-management codes on the national rail, paid on top of the visit.
Same-day appointments, walk-ins welcome, labs and X-ray in the building, and a sliding-fee scale. Patients who can get in the same day tend to pick up when the care team calls.
The clinic already bills CCM for Medicare patients inside eClinicalWorks, with the patient portal running on the same system. Consent, care plans and monthly documentation are habits here already.
A Medicare Shared Savings Program participant since 2024, now on the ENHANCED track for 2026. The clinic has already chosen to be measured on the cost and quality of its patients' care.
Two changes landed close together. The bundled care-management code went away, and remote monitoring gained short-window codes. Both pay a rural health clinic more for work this clinic already does.
Through September 2025, a rural health clinic billed care management as one bundled code, G0511. Since October 2025 it bills chronic care management, remote monitoring, advanced primary care management, behavioral health integration and transitional care as individual codes at national non-facility amounts, in addition to the all-inclusive rate for the visit (CMS MLN006398, January 2026). Every figure on this page is priced at the national amounts a rural health clinic is paid for these codes.
New codes pay for 2 to 15 days of device data and for the first 10 minutes of monthly management. A patient who transmits for part of a month, or for two weeks after a hospital stay, is now billable. On this forecast the two new codes carry $49,343 over 24 months, about 9.7% of net reimbursement.
These codes are paid on top of the all-inclusive rate and do not need a visit slot. A month of monitoring and care management adds revenue without taking an appointment from the provider's schedule. With one practitioner, that matters more than the rate.
Tennessee's $206.9 million Rural Health Transformation award names remote monitoring in the state plan's technology pillar, which tells you where the state expects rural care to go.
One practitioner sees every patient here. Every task between visits, from enrollment calls to reading reviews to the monthly time logs that make a care-management claim billable, competes with the visit schedule. This program moves 3,531 care-team hours over 24 months, about 1.7 full-time staff, onto CoachCare's payroll. The clinic has one provider.
Referrals from one provider run about 6 a month. With phone outreach on top, the program reaches about half of its possible enrollments (132 of 271 at month 24) and $130,517 of net reimbursement over two years, which leaves three-quarters of the 24-month revenue on the table. A CoachCare-funded enrollment specialist working the clinic's panel directly is worth +$378,170 of 24-month net reimbursement and +$169,726 net to the clinic. The specialist can't raise a ceiling. It fills RPM by month 9, and it is CoachCare's payroll, embedded in the fee.
A second specialist reaches the ceilings sooner and adds $32,485, which this panel does not need. Once the specialist is working, the binding constraint is the number of Medicare patients, not enrollment pace. The levers that move the number from here are the Medicare Advantage plan terms, the count behind the 600 itself, and the next programs: transitional care at discharge and behavioral health integration.
| Scenario | 24-mo net reimb. | Net to the clinic | Margin | Ceiling reached RPM / CCM / APCM |
|---|---|---|---|---|
| Modeled: 600 patients, 1 provider, 1 enrollment specialist | $508,687 | $217,586 | 42.77% | M9 / M6 / M3 |
| No on-site enrollment specialist | $130,517 | $47,860 | 36.67% | None in 24 months |
| A second on-site enrollment specialist | $541,172 | $231,976 | 42.87% | M5 / M4 / M2 |
| Two referring clinicians | $513,269 | $219,599 | 42.78% | M8 / M5 / M3 |
| Traditional Medicare only (~263 patients) | $239,752 | $97,144 | 40.52% | M5 / M3 / M2 |
| Panel of 450 | $393,933 | $166,152 | 42.18% | M7 / M5 / M3 |
| Panel of 800 | $649,434 | $280,743 | 43.23% | M11 / M7 / M4 |
Each row is a full recalculation of the Value Analysis at national amounts with one input changed.
This is not a new program dropped on a clinic that has none. The clinic built chronic care management itself, inside the chart it already runs. CoachCare extends it.
None of this is replaced. CoachCare works as the clinic's extension inside eClinicalWorks, and the clinic's CCM becomes one program inside a larger service line.
CoachCare carries all four, inside the chart the clinic already uses, and the clinic keeps its patients, its protocols and its claims.
A named service line with its own P&L and scorecard, built on the Medicare patients the clinic already sees, inside eClinicalWorks. Remote monitoring for the patients whose blood pressure and glucose produce readings, chronic care management for patients with two or more chronic conditions, and advanced primary care management where the monthly bundled code fits better.
| 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 covers 2–15-day months |
| 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 program the clinic runs today |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.37 · $53.78 · $117.24/mo | The primary-care panel by complexity; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | $220.11 / $298.60 per discharge | Hospital and skilled-nursing discharges; $0 in the forecast |
| Behavioral health integration | 99484 | $57.45/mo | The next program; $0 in the forecast |
Amounts are the CY2026 Medicare physician fee schedule national non-facility rates. A rural health clinic is paid these amounts for each code in addition to the all-inclusive rate, and every figure on this page is priced on them.
The clinic participates in a Medicare Shared Savings Program ACO that moved to the two-sided ENHANCED track for 2026. On that track, total cost of care and quality for the clinic's attributed Original Medicare patients carry downside as well as upside. The service line on this page works on both sides of that ledger.
Blood-pressure control and diabetes control are among the quality measures a primary-care ACO is scored on. They move when readings arrive every week and someone acts on them, not once a quarter at a visit.
The Value Analysis models about 18.0 hospitalizations avoided over 24 months, roughly $270,000 of acute-care cost at $15,000 an admission. On a two-sided track, that is total cost of care.
ACO assignment runs on primary-care services, and CCM and APCM are primary-care services. A documented monthly touch from the clinic helps keep its patients attributed to the clinic.
Middleton sits about 15 miles from the nearest hospital, a critical access hospital, and about 40 from tertiary care. For a patient whose blood pressure is drifting, a reading at home beats a drive to the clinic. Every device ships with its own cellular connection, so the program does not depend on home internet or a smartphone app; about one household in five in the county has no broadband subscription.
When an enrolled patient comes home from one of the area's hospitals or a skilled-nursing stay, three touches follow inside two weeks. The first two are the transitional-care contact and visit; the device keeps transmitting the whole time, and the patient lands back in RPM when the episode closes.
Reach the patient, reconcile medications against the discharge instructions, confirm the device is transmitting.
Review symptoms and readings, work through barriers to the plan, confirm the follow-up visit at the clinic.
Close the episode or extend it. Anything still trending goes through the escalation engine below.
Chest pain, new shortness of breath, stroke signs, fainting, worst-ever headache. CoachCare's urgent and emergent policy overrides any preference. If the patient refuses, the clinic is told; otherwise CoachCare calls 911.
Out-of-range but not emergent findings go to the clinic team member the provider designates, with the readings, the symptom check and a recommended next step attached.
A retake back in range and a clean symptom check close the loop with a chart note. The provider's inbox is kept for things that need a decision.
An unreachable patient is tried again on schedule, the clinic hears at each decision point, and a patient who stops transmitting is worked before a billing month is lost.
The clinic runs on eClinicalWorks, and its CCM already lives there. This plan is priced on CoachCare's eClinicalWorks integration. Enrollment flags and orders are placed inside eClinicalWorks; monitored vitals, Evidence of Care documents, care plans and enrollment status post to the chart every month; claims are created in the eClinicalWorks billing module with the care-management codes on them, and the clinic files them as it does today.
The provider 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 with CoachCare's care team, and the escalation engine routes anything that needs the provider.
Every month, vitals, the Evidence of Care document, the care plan and enrollment status post to the eClinicalWorks chart. One chart, no second system.
Claims are created in the eClinicalWorks billing module with the care-management codes on them, and the clinic files them on its own claim. No PDFs, no re-keying.
A 24-month forecast for the RPM + CCM + APCM stack: the clinic's 600 Medicare patients, all in scope from month one, one referring provider, one CoachCare-funded enrollment specialist on site, phone outreach, the national amounts a rural health clinic is paid, and the eClinicalWorks integration. Transitional care and behavioral health integration are named above and not in these numbers.
| Program | Net reimb. | CoachCare fees | Net to the clinic |
|---|---|---|---|
| RPM | $263,598 | $146,154 | $117,444 |
| CCM | $171,183 | $84,160 | $87,023 |
| APCM | $73,906 | $40,257 | $33,649 |
| Implementation, eClinicalWorks integration, outreach | — | $20,531 | −$20,531 |
| 24-month total | $508,687 | $291,101 | $217,586 |
| The enrollment specialist, care management and device logistics are CoachCare's expense: embedded in the fee, never billed to the clinic separately and never deducted from its margin. | |||
24-month margin: 42.77% of net reimbursement (Year 1 40.73%, Year 2 44.29%).
Year 1 is $88,000 net to the clinic on $216,076 of net reimbursement; Year 2 is $129,586 on $292,610.
| Year 1 | Year 2 | |||||
|---|---|---|---|---|---|---|
| Program | Net reimb. | Fees | Net to clinic | Net reimb. | Fees | Net to clinic |
| RPM | $105,654 | $57,673 | $47,981 | $157,944 | $88,481 | $69,463 |
| CCM | $75,496 | $37,116 | $38,380 | $95,687 | $47,043 | $48,644 |
| APCM | $34,926 | $19,024 | $15,902 | $38,980 | $21,232 | $17,748 |
| Implementation, eClinicalWorks integration, outreach | — | $14,263 | −$14,263 | — | $6,268 | −$6,268 |
| Year total | $216,076 | $128,077 | $88,000 | $292,610 | $163,024 | $129,586 |
| Margin (net to the clinic ÷ net reimbursement) | Year 1: 40.73% | Year 2: 44.29% | ||||
Recurring care-management and monitoring volume over 24 months, filed on the clinic's own claim.
Blood pressure and glucose for the hypertension and diabetes cohorts, between visits instead of at them.
About $270,000 of acute-care cost not spent, at $15,000 an admission, and that many trips out of the county not taken.
About 3,531 care-team hours of monitoring, outreach and documentation, carried by the service line instead of the clinic's staff.
APCM reaches its ceiling of 63 enrollments in month 3, CCM its ceiling of 72 in month 6, and RPM its ceiling of 136 in month 9. From there the census holds at 271 program enrollments, 177 unique patients, and Year 2 runs at the full monthly rate. The binding constraint is the size of the Medicare panel, not enrollment pace. The first 90 days, modeled: 26 active enrollments in month 1, 69 in month 2, 128 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 136 | 600 in scope × 65% eligible (390) × 35% acceptance | Month 9 |
| CCM | 72 | 600 × 40% (240) × 30% | Month 6 |
| APCM | 63 | 600 × 35% (210) × 30% | Month 3 |
| At month 24 | 271 | Program enrollments = 177 unique patients | — |
Every ceiling above is reached with one CoachCare-funded enrollment specialist working the clinic's panel. Without the specialist, the program reaches about half of its possible enrollments and 24-month net reimbursement falls to $130,517. The difference, $378,170 of net reimbursement and $169,726 net to the clinic, costs the clinic nothing: the specialist is CoachCare's payroll.
Medicare Advantage plans, most of the Medicare population in Hardeman County, reimburse these code families at a floor of the Medicare amount; individual plan contracts set their own terms. Confirming those terms, and how the clinic's 600 Medicare patients split between traditional Medicare and Advantage, is the first piece of discovery. After that the growth is in transitional care at discharge and behavioral health integration.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposal is narrower than the headline suggests. Below is what it does to the forecast on this page, repriced at the national amounts a rural health clinic is paid, the same basis the forecast uses.
The proposals reach the remote-monitoring codes. Chronic care management and advanced primary care management are not targeted, and on this forecast those two carry $245,089 of the $508,687 in 24-month net reimbursement. Their amounts still drift a point or two with the conversion factor, so $4,339 of the $29,431 total sits outside remote monitoring.
Two contingencies are already in build. One is an unbundled arrangement, with the software platform, device logistics and program enablement priced separately. The other is an MSO-style arrangement in which CoachCare manages the staffing while the clinic owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model shows the direction: remote care paid as a risk-based per-member-per-month amount, with part of each payment held back and reconciled against outcomes. A clinic already on a two-sided ACO track, with a consented panel and a year of readings behind it, is set up for that kind of payment.
Three numbers, each smaller than the last because each sits on a larger base. Both bars use one shared dollar scale, so the coral can be compared directly.
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 advanced primary care management tier weights. Enrollment, acceptance and mix held constant, so this is the rate change alone.
National non-facility amounts, CY2026 final against the CY2027 proposal. These are the amounts a rural health clinic bills on, so this table and the repricing above use the same basis.
| 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% |
Section 1848(c)(7) of the Act phases any reduction of 20 percent or more over two years, so CY2027 is the capped year for the device-supply and short-window codes and the rest of the change lands no earlier than CY2028.
Comments on CMS-1848-P closed September 14, 2026. The final rule is expected in early November and takes effect January 1, 2027. CoachCare is working the remote-monitoring provisions in comment and will rerun this forecast against the final rates the week they publish.
CoachCare runs the service line's engine while the provider governs protocols and every clinical decision. Launch needs no new hires and no capital. The eClinicalWorks integration is built alongside onboarding, so the first enrollments do not wait for it.
eClinicalWorks integration scoped and started; a named program lead at the clinic; P&L and scorecard; claim configuration for the individual care-management codes; the clinic's current CCM patients reconciled into the program; protocol sign-off for the hypertension and diabetes pathways; the discharge trigger wired to the three-touch cadence.
APCM and CCM across the chronic-condition panel, RPM for the hypertension and diabetes cohorts, the enrollment specialist working the clinic, and the post-discharge cadence live with the first enrollment.
APCM fills in month 3, CCM in month 6, RPM in month 9. A monthly scorecard goes to the clinic, with the blood-pressure and diabetes control numbers the ACO reports on.
Re-check eligibility against the clinic's own chart counts, add transitional care at every hospital and skilled-nursing discharge, and stand up behavioral health integration on the same engine.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this fits Advanced Family Medical Center specifically.
Individual care-management codes at national amounts, on top of the all-inclusive rate, on the clinic's own claim. The change from G0511 is the reason this forecast exists, and the program is built around it.
The enrollment specialist, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The 1.7 FTE-years of work in the forecast never touch the clinic's staffing plan or the provider's schedule.
Orders go out of eClinicalWorks; vitals, Evidence of Care documents, care plans, enrollment status and claims come back into it. The clinic's existing CCM stays where it is and grows.
Weekly blood pressure and glucose readings and a documented monthly touch are what move blood-pressure and diabetes control and keep patients attributed. The revenue on this page is fee-for-service either way.
Every device carries its own cellular connection, so nothing depends on home broadband or a smartphone. Patient materials are written for a rural Medicare population, and every patient has a named care manager who calls.
Fees are per active patient per month, with no capital outlay and no payroll ramp. Medicare Advantage plans reimburse these codes at a floor of the Medicare amount, with terms set plan by plan, and the panel is reconciled by payer before anything goes to paper.