Ongoing programs
Chronic Care Management (CCM)
Continuous support between visits for long-term conditions
Living with diabetes, high blood pressure, heart disease, or lung disease means your health doesn't pause between appointments. Our Chronic Care Management (CCM) program gives you a written care plan, a team that checks in every month, and someone to call any time of day.
- Who
- 2+ chronic conditions
- Where
- By phone, in the office, or at home
- Coverage
- Medicare Part B
CCM
A written care plan and a team that checks in every month.
At a glance
What to know before you start.
- 01
Who it's for
Adults living with two or more long-term conditions that put their health at significant risk.
- 02
Where care happens
Mostly by phone and through the patient portal between visits, alongside your regular office visits or house calls.
- 03
Coverage
Medicare Part B covers CCM. Coinsurance and your deductible may apply; many other plans cover it too.
- 04
How to start
Ask your Dr.NYC physician at your next visit, or call us. Enrollment requires your consent.
Who qualifies
Is this right for you?
CCM is for patients with at least two chronic conditions that are expected to last at least 12 months and put them at significant risk of decline. Common examples include:
Whether a service is right for you is a clinical decision you make together with your physician.
- Diabetes or prediabetes with other conditions
- High blood pressure and heart disease, including heart failure
- COPD, asthma, or other chronic lung disease
- Chronic kidney disease
- Arthritis, osteoporosis, or chronic pain
- Depression, anxiety, or dementia alongside other conditions
What's included
What the program includes
CCM adds structure and continuity to the care you already receive.
Comprehensive care plan
A written plan covering your conditions, goals, medications, and who does what — shared with you and your caregivers.
Monthly check-ins
Regular calls from our care team to review symptoms, medications, and upcoming needs.
Medication management
Help keeping track of prescriptions, refills, side effects, and interactions.
24/7 access
A phone line answered around the clock, so you always know who to call.
Care coordination
Communication with your specialists, pharmacies, labs, and home health agencies.
Transitions of care
Follow-up after an ER visit or hospital stay to update your plan and prevent setbacks.
Getting started
What happens at your first visit.
- 1
Talk with your physician
We review your conditions and explain how CCM works, including any cost-sharing, and ask for your consent.
- 2
Build your care plan
Together we set goals, list medications, and decide how often we check in.
- 3
Monthly support
Our care team calls you each month and updates the plan as things change.
At home or in the office
Care where it works best for you.
For homebound patients
- CCM pairs naturally with scheduled house calls
- Caregivers can join monthly calls
- Remote monitoring can be added for daily readings
For office patients
- Check-ins between your regular office visits
- Labs and vaccines at your office appointments
- Portal messages for quick questions
Insurance & coverage
What your plan may cover.
Medicare Part B covers Chronic Care Management for eligible patients. Because it is a Part B service, your usual deductible and 20% coinsurance may apply unless you have supplemental coverage that pays them. Many Medicaid and commercial plans cover CCM as well.
You can stop the program at any time. Only one practice can bill Medicare for CCM in a given month, so let us know if another doctor already provides it.
We accept most insurance plans, including Medicare and Medicaid, and nobody is turned down. Call (212) 888-2222 and we'll check your benefits.
Is CCM a separate doctor?
No. CCM is run by your own Dr.NYC physician and care team. It adds support between the visits you already have.
How much time does it take?
Usually a short monthly phone call, plus any follow-up you need. Some months require more coordination than others.
Does Medicare cover Chronic Care Management?
Yes, Medicare Part B covers CCM for patients with two or more qualifying chronic conditions. Standard Part B cost-sharing may apply.
Can my daughter or aide be part of the calls?
Yes. With your permission, family members and caregivers can take part in check-ins and receive a copy of your care plan.
Can I combine CCM with remote patient monitoring?
Often, yes. Many patients use Remote Patient Monitoring for daily readings, which the CCM team reviews as part of your plan.
Can I leave the program?
Yes. You can end CCM at any time by telling our office; it takes effect at the end of the current month.
Related services
Remote Patient Monitoring (RPM)
Connected devices that send your readings to your care team between visits.
Learn more
House Calls · MD2Home®
Physician visits at home for patients who are homebound or can't easily travel.
Learn more
Diabetes Prevention Program (DPP)
A year-long lifestyle program for adults with prediabetes.
Learn more
Dr.NYC Health + Systems®
Your doctor, in the office or at your door.
Most plans accepted. Nobody is turned down. Everybody is seen.
If you are experiencing a medical emergency — chest pain, severe shortness of breath, stroke symptoms, uncontrolled bleeding or severe injury — call 911 or go to the nearest emergency room.