This health center sees nearly 4,800 Medicare patients across ten counties, a third of them dually eligible, and has no Medicare revenue line yet for the month of care between their visits. Since last October a health center bills that month as its own codes, at the national amounts, on top of every visit. The panel is large enough that the only real question is how fast it enrolls, and the people who do the enrolling and the monthly work are ours. This is the 24-month plan, inside eClinicalWorks, with CoachCare staffing the program.
Two counts, two jobs. 1,384 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 2,139 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $1,252,709 of the $2,933,892 is the health center's after CoachCare's fees.
A health center that has served the Florida Big Bend and eastern Panhandle for more than forty-five years, from ten medical sites and a mobile unit across ten counties, a recognized patient-centered medical home that lifted blood-pressure control from 51.3% to 56.35% over five years and holds diabetes poor control at 23.0%. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 22,997 patients in 2024, 4,431 of them 65 or older and 4,795 with Medicare as their primary coverage. Every figure on this page is built on those 4,795 and nothing outside them.
1,439 of the 4,795 Medicare patients also carry Medicaid. That share is what puts the top advanced primary care management tier, G0558 at $117.24 a month, in reach for a large part of the panel and makes it the best-paying monthly code on this page.
Blood-pressure control is 56.35%, up from 51.3% in 2019, and diabetes poor control is 23.0%. Statin therapy is 78.07%. Those are the measures continuous readings and a documented monthly touch move, and they are the measures the health center reports every year.
The registries, the team-based primary care and the quality reporting a remote program runs on are already in place across the sites. A health center organized this way is the right one to be paid for the month between visits.
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, and no care-manager or monitoring role is posted. CMS suppresses claim lines under eleven beneficiaries, and care management billed on the health-center claim would not appear in that file regardless. The 5,953 patients with hypertension and the 3,057 with diabetes are seen a few times a year. 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 one of the acute-care hospitals across the health center's service area can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $238,997 of reimbursement over 24 months before denials and bad debt, about 8.1% 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. With 30.0% of the Medicare panel dually eligible, the tier mix on this forecast blends to $61.01 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 the acute-care hospitals across its service area; 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: the health center's own 4,795 Medicare patients, all of them in scope from month one, eighteen physicians and nurse practitioners plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the eClinicalWorks integration. Transitional care, behavioral health integration and Florida Medicaid are not in these numbers.
After denials and coinsurance bad debt; $866,287 in Year 1 and $2,067,605 in Year 2.
42.70% of net reimbursement after CoachCare's fees: 41.39% in Year 1, 43.24% in Year 2.
Unique patients in active remote care at month 24, up from 984 at month 12 as remote monitoring keeps enrolling across the panel.
RPM 1,061 + CCM 575 + APCM 503 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $1,284,670 | $733,805 | $550,866 |
| CCM | $1,072,234 | $546,434 | $525,800 |
| APCM | $576,987 | $325,487 | $251,500 |
| Implementation, eClinicalWorks integration, outreach | — | $75,457 | −$75,457 |
| 24-month total | $2,933,892 | $1,681,183 | $1,252,709 |
| 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 | $866,287 | $507,704 | $358,583 | 41.39% |
| Year 2 | $2,067,605 | $1,173,478 | $894,126 | 43.24% |
| 24 months | $2,933,892 | $1,681,183 | $1,252,709 | 42.70% |
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 $1,311,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 19,382 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 503 enrollments in month 8 and CCM its ceiling of 575 in month 15. Remote monitoring never plateaus inside the forecast: it climbs the full two years to 1,061 of a 1,091 ceiling at month 24 and is still rising. Month 24 is 2,139 program enrollments, 1,384 patients, up from 984 at month 12. The binding constraint here is enrollment throughput, not the size of the Medicare panel. The first 90 days, modeled: 60 new enrollments in month 1, 100 in month 2, 140 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 1,091 | 4,795 in scope × 65% eligible (3,117) × 35% acceptance | Still climbing (M24: 1,061) |
| CCM | 575 | 4,795 × 40% (1,918) × 30% | Month 15 |
| APCM | 503 | 4,795 × 35% (1,678) × 30% | Month 8 |
| At month 24 | 2,139 | Program enrollments = 1,384 patients | — |
On a panel this large the on-site enrollment specialist does more than speed the ramp: it captures more of the panel inside 24 months. Without one, 24-month net reimbursement is $2,115,111 and remote monitoring reaches 679 enrollments; the modeled specialist lifts those to $2,933,892 and 1,061, worth $818,781. The specialist works the sites and the mobile-unit schedule, and the role is CoachCare's payroll, not a health-center cost.
Because remote monitoring is still climbing at month 24, the levers that move this forecast are enrollment capacity and the second rail. A second on-site specialist takes 24-month net reimbursement to $3,408,997 and a third to $3,672,097, filling remote monitoring more than a year sooner. And most of the health center's chronic-disease volume sits on the Florida Medicaid rail below, which pays for remote monitoring and basic chronic care management and is scoped separately.
The health center's panel is heavily low-income, and most of its 5,953 hypertensive and 3,057 diabetic patients are on Medicaid or uninsured. Florida Medicaid covers remote patient monitoring and basic chronic care management on its fee schedule, so the same devices and the same monthly work reach a second, larger population alongside the Medicare forecast on this page.
Florida Medicaid Practitioner Fee Schedule, January 1, 2025. Florida Medicaid does not pay for advanced primary care management, transitional care management, complex chronic care management or behavioral health integration; those are Medicare-only rails here.
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 discharge from any of the acute-care hospitals across the health center's service area 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 that works across the Big Bend and eastern Panhandle is not the one built for a single city clinic. The sites are spread across ten counties, several of them rural, many patients are a long drive from the nearest specialist, and home broadband is not a safe assumption. 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 is what makes it usable in the rural counties the health center covers.
Between visits the program follows blood pressure, weight and glucose without another trip across the county. For a patient an hour from the clinic, a reading and a phone call do the work a windshield used to, and the visit is saved for what needs the room.
Device instructions and call scripts in both languages, matched to the language on the patient's chart and written at a low reading level. A monthly documented touch in the patient's own language reaches people an office calendar does not.
The on-site enrollment specialist works the site days and the mobile-unit schedule, so consent, device setup and the first reading can happen face to face wherever the health center already goes, not only at the main campus.
Lists come from the hypertension and diabetes registries first, then by payer, so the Medicare rail and the Florida Medicaid rail each get the patients who belong on them and nobody is worked twice.
Twelve of the eighteen referring clinicians are nurse practitioners. The care-management codes are built for general supervision, so the team as it stands today fits the way the codes work.
The health center serves ten counties from ten medical sites and a mobile unit, from Tallahassee out to the rural coast and the Suwannee River valley. Its Medicare population is spread thin across that geography, heavily low-income, and, in most of these counties, more likely to be in a Medicare Advantage plan than not.
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 $1,649,221 of the $2,933,892 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $27,506 of the $149,638 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 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 on-site enrollment specialist working the site days and the mobile-unit schedule; the post-discharge cadence live from day one.
APCM fills in month 8 and CCM in month 15, while remote monitoring keeps enrolling; monthly scorecard to the executive team, with the blood-pressure control and diabetes measures the health center reports each year.
Add a second on-site enrollment specialist to fill remote monitoring faster, size and launch the Florida Medicaid line from the registries, bring transitional care to every discharge, and add behavioral health integration as the next arm alongside the health center's own behavioral-health services.
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.