Two of every three Medicare patients at Jordan Health are dually eligible. That mix makes advanced primary care management worth more here than at almost any health center in the country. The health center already does the between-visit work for its Medicaid members through Health Home. Since January, Medicare pays for that month of care too, as individual codes at national rates on top of every visit. This is the 24-month plan to put cellular devices, documentation and a Medicare revenue line under work Jordan Health already knows how to do, with CoachCare staffing the program inside eClinicalWorks.
Two counts, two jobs. The headline is 737 unique patients at month 24; the enrollment chart and the Scenario Explorer show 1,130 active program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments.
A health center that has served Rochester's northeast and west neighborhoods for more than a century, runs nine sites with urgent care, imaging and an in-house pharmacy under its own roof, holds PCMH and Joint Commission recognition, and operates a Medicaid Health Home care-management agency. It carries a Medicare panel in which two of every three patients are dually eligible and a hypertension registry most practices would call a specialty clinic. An organization that already does the between-visit work is the right organization to be paid for it.
Medicare is 13% of the panel, and 68.6% of that Medicare panel is dually eligible, the highest share of any health center CoachCare has modelled. That share is what defines the top tier of advanced primary care management. Every figure on this page is built on the 2,498 and nothing outside it.
Forty-three percent of the panel carries a hypertension diagnosis and one patient in five a diabetes diagnosis. Blood pressure is controlled in 58.1% of the hypertensive patients and diabetes is poorly controlled in 35.5% of the diabetic patients. Those are the two measures daily readings and a monthly call are built to move.
Jordan Health is a New York Medicaid Health Home care-management agency: care managers who coordinate treatment, transportation, housing, benefits and medications for members with two or more chronic conditions. The human layer of between-visit care exists here for Medicaid. Medicare has no revenue line under it yet.
An in-house pharmacy, a clinical-pharmacy service line, urgent care and imaging at the main center, and an eClinicalWorks chart shared across every site. A blood-pressure trend that does not respond is usually a refill that did not happen, and here the pharmacist is down the hall.
One structural fact completes the picture: no remote patient monitoring, chronic care management or advanced primary care management program is visible at meaningful scale in the health center's CY2024 Medicare Part B claims. CMS suppresses claim lines under eleven beneficiaries, and care management billed on the health-center claim would not appear in that file regardless. The care-management model the health center runs for Medicaid has no Medicare revenue line under it yet.
Eight of the health center's nine sites sit in the northeast and west neighborhoods of Rochester, where 27.8% of residents live in poverty and one older adult in five does, one patient in five speaks limited English, and a third of the panel is Hispanic or Latino. Patients with hypertension and diabetes are seen in person a few times a year. Daily readings and a monthly call, in English or Spanish, are how a health center reaches them in between.
Three things changed at once for a New York health center in 2026: how care management is billed, what remote monitoring can bill for, and which of Medicare's monthly codes fits a dually eligible panel.
Through 2025, a health center billed care management as one bundled code, G0511. From January 2026, Federally Qualified Health Centers bill chronic care management, remote monitoring and advanced primary care management as individual codes at 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.
New CPT 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 hospital discharge can now be followed by a billable two-week monitoring window, next to the standard monthly stack. On this forecast the two codes carry $174,554 of gross reimbursement over 24 months, about 8.9% of net reimbursement.
Advanced primary care management pays a monthly amount per patient in three levels. Level 3, G0558, is defined by dual eligibility with two or more chronic conditions, and at the New York amount it pays $113.17 a month. With 68.6% of the Medicare panel dually eligible, the health center's panel is a level-3 panel. That single fact is why the forecast on this page is worth more per patient than a typical primary-care practice'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 dual eligibility makes it the better monthly code, which on this panel is most of the time.
| Service | Codes | CY2026, New York locality 99 | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $20.46 setup · $49.42/mo | Hypertension, diabetes and heart-failure cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $49.87 + $40.03 add'l · $25.10 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $63.92 + $48.67 add'l | Two or more chronic conditions; the longitudinal wrapper for the non-dual panel |
| Advanced primary care management | G0556 · G0557 · G0558 | $15.80 · $51.96 · $113.17/mo | The primary-care panel by complexity tier; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | $212.18 / $288.02 per discharge | Any hospital discharge of a health-center patient; not in the forecast below |
| Behavioral health integration | 99484 | $55.64/mo | The next arm; not in the forecast below |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 14605 (National Government Services, New York locality 99), the basis the Value Analysis below is priced on. A Federally Qualified Health Center bills the care-management codes at national non-facility amounts in addition to the PPS encounter, and the national amounts run 3 to 6 percent above the New York locality on every code in this table, so the figures on this page are the conservative reading.
Advanced primary care management is Medicare's monthly payment for looking after a primary-care patient, with no time threshold to document. It pays in three levels, and the top level is defined by the thing this panel has more of than almost any other: dual eligibility. At a typical primary-care practice one patient in five qualifies for the top tier. Here it is two in three.
One chronic condition. The forecast assumes one patient in ten on this panel sits here.
Two or more chronic conditions. Half of the enrolled panel in the forecast.
Two or more chronic conditions and a Qualified Medicare Beneficiary. Forty percent of the enrolled panel in the forecast, weighted below the 68.6% dual share to allow for members whose Medicaid does not carry the QMB designation.
Blended across the three levels the forecast assumes $72.83 a month per APCM patient before denials and coinsurance. The APCM arm alone is $385,444 of the 24-month net reimbursement on 262 enrollments, and it fills in month 5, the fastest of the three programs, because eligibility is a chart fact rather than a device.
A Qualified Medicare Beneficiary owes no Medicare cost sharing, so the monthly code carries no coinsurance for the patient. The usual first objection to a monthly program, the twenty percent, does not exist for most of this panel. Enrollment conversations are about the care, not the bill.
Health Home pays for a month of care coordination for the Medicaid side of a dually eligible member; APCM pays for the same month on the Medicare side, for the clinical management. They are different services with different documentation, and a health center that already runs the first is organized to run the second.
The health center's patients are admitted to four acute-care hospitals across the city, and in the FY2026 readmissions file the two nearest the health center's sites carry excess-readmission ratios above 1.0 for heart failure, COPD and pneumonia. The thirty days after a discharge are where a chronic-disease admission repeats. The program's job is to know the day the patient goes home, catch the decompensation a week earlier by phone and by reading, and route it to the clinic instead of back to a bed.
Any hospitalization or observation stay in the last 60 days triggers three touches inside two weeks. The trigger is the hospital admission and discharge alert; wiring that alert feed into the program is a first-month implementation item, and 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, in English or Spanish, 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. 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 schedule, the clinic is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
A 24-month forecast for the RPM + CCM + APCM stack: the health center's own 2,498 Medicare patients, all of them in scope for Year 1, nineteen physicians, nurse practitioners and physician assistants in adult medicine plus CoachCare's enrollment outreach, New York locality 99 rates for ZIP 14605, and the eClinicalWorks integration. Transitional care, behavioral health integration and the national health-center rate rail are not in these numbers.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $941,884 | $537,263 | $404,622 |
| CCM | $640,755 | $322,195 | $318,560 |
| APCM | $385,444 | $219,843 | $165,600 |
| Implementation, eClinicalWorks integration, outreach | — | $50,869 | −$50,869 |
| 24-month total | $1,968,082 | $1,130,170 | $837,913 |
| 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. | |||
24-month margin: 42.58% of net reimbursement (Year 1 41.73%, Year 2 43.08%).
Year 1 is $308,806 net to the health center on $739,951 of net reimbursement; Year 2 is $529,106 on $1,228,131. Month 1 is −$4,692 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring care-management and monitoring volume over 24 months, filed on the health-center claim by the health center's own reimbursement team.
Blood pressure, weight and glucose, a continuous picture of the hypertension, diabetes and heart-failure cohorts between visits.
About $1.01M in acute-care cost that never gets spent, at $15,000 per admission.
About 13,389 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 262 enrollments in month 5, CCM its ceiling of 300 in month 8, and RPM keeps climbing until month 13, when it reaches 568. From there the census holds at 1,130 active enrollments, 737 unique patients. The binding constraint on this forecast is the size of the Medicare panel, not enrollment capacity. What moves it is the top of the health center's own five-year Medicare range, the hospital discharges, and behavioral health integration as the next arm.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 568 | 2,498 in scope × 65% eligible × 35% acceptance | Month 13 |
| CCM | 300 | 2,498 × 40% × 30% | Month 8 |
| APCM | 262 | 2,498 × 35% × 30% | Month 5 |
| At month 24 | 1,130 | Active program enrollments = 737 unique patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working the health center's sites. Without that specialist the same ceilings are reached months later, remote monitoring does not fill until month 19, and the 24-month net reimbursement falls to $1,717,459. The specialist cannot raise a ceiling, but reaching it in month 13 instead of month 19 is worth $250,623 over 24 months, and it is CoachCare's payroll.
A Federally Qualified Health Center bills the care-management codes at national non-facility amounts on top of the PPS encounter. The forecast on this page uses the New York locality amounts, which sit below national on every code in the basket. Priced at the national amounts with the same census, 24-month net reimbursement is $2,044,749, and because CoachCare's fees are per active patient per month, the whole difference, $76,667, is the health center's: $914,579 net over 24 months at a 44.73% margin.
The health center runs eClinicalWorks across every site, with the healow portal for patients, so this plan is priced on the eClinicalWorks interface CoachCare already operates for more than forty eClinicalWorks clients. CoachCare connects to it through an HL7 and FHIR integration: eligibility flags and referral orders leave the chart; monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The health center's own reimbursement team files the health-center claims with the care-management codes on them. The integration scope is confirmed in contracting.
the integration is built alongside onboarding, training and care-team assignment; the first enrollments do not wait for it.
a physician, NP or PA flags an eligible patient and submits the referral from inside eClinicalWorks; CoachCare picks it up, ships the device and reaches the patient in their language.
claims arrive billing-ready in the workflow the health center's own reimbursement team already runs for the health-center claim. No PDFs, no re-keying.
CoachCare operates as the service line's engine while the health center's physicians and advanced practitioners govern protocols and every clinical decision. Full-service delivery means 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 referral orders.
eClinicalWorks integration scoped and started; named program lead at the health center; P&L and scorecard; claim configuration with the reimbursement team; protocol sign-off for the hypertension, diabetes, heart-failure and COPD pathways; the hospital admission and discharge alert feed wired to the three-touch cadence; the bilingual care team assigned; a working rule for how the program and the Health Home care managers share a dually eligible member.
APCM across the dually eligible panel, CCM across the rest of the two-plus-condition panel, and RPM for the hypertension and diabetes cohorts; CoachCare's on-site enrollment specialist working the health center's sites; the post-discharge cadence live from day one.
APCM fills in month 5, CCM in month 8, RPM in month 13; monthly scorecard to the executive team and the board, with the blood-pressure and A1c control measures the health center reports to HRSA every year.
Re-validate eligibility against chart data, bring transitional care to every hospital discharge, add behavioral health integration as the next arm, and take the same infrastructure to the Medicare Advantage contracts one plan at a time.
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, priced at the health center's own New York locality amounts rather than national averages.
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 $1,026,198 of the $1,968,082 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $15,613 of the $105,489 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's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months. A health center that already documents a month of care for its Medicaid members through Health Home is closer to that destination than most.
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 red can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at National Government Services New York locality 99 amounts, non-facility, 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, the rail a health center bills the care-management codes on, so the movement can be read without a locality in the way. The repricing above uses the New York amounts; the two bases do not reconcile to the dollar, by design.
| 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.
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 on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this fits Jordan Health specifically, not remote care in general.
Individual care-management codes on the health-center claim, in addition to the PPS encounter, filed by the health center's own reimbursement team. The 2026 change from the bundled code is the reason the forecast on this page exists, and the program is built around it.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll, and the care team assigned to this panel works in English and Spanish. The 6.4 FTE-years of work in the forecast never touch the health center's staffing plan.
The health center already coordinates a month of care for its Medicaid members through Health Home. This plan adds cellular devices, documented monthly clinical management and Medicare billing to that shape of care, and sets a working rule for how the two programs share a dually eligible member. Where the care team stands today is the first discovery question.
An HL7 and FHIR integration carries referral orders out and vitals, documentation, enrollment status and billing-ready claims back in. One chart for clinicians across nine sites, one workflow for the reimbursement team, no second system.
Enrollment conversations that lead with the care because the patient owes no coinsurance, a top-tier APCM code documented correctly every month, and the QMB and Medicaid crossover handled on the claim so nothing is billed to a patient who cannot be billed.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is measured twice before it goes to paper. The forecast and the workbook behind this page are yours to keep either way.