First Choice already sees 3,288 Medicare patients, 5,410 of them with high blood pressure and 2,671 with diabetes, a few times a year. Since last October, Medicare pays a health center for the month of care between those visits as its own codes, at national amounts, on top of every encounter. On a panel this size that is a seven-figure line the center is not billing today, and the dually eligible patients make the monthly code worth the most. This is the 24-month plan, inside eClinicalWorks, with CoachCare staffing the program.
Two counts, two jobs. 970 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 1,488 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $1,032,948 of the $2,436,642 is the health center's after CoachCare's fees.
A Section 330 health center that has grown since 2007 into eight clinical sites across Macon and Warner Robins, two on-site 340B pharmacies and school-based clinics, cut its uninsured share from 36.5% to 19.3% of patients in five years, lifted blood-pressure control to 62.61% and brought diabetes poor control down from 29.51% to 24.56%, all on a panel where 95 percent of patients live at or below the poverty line. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 11,503 patients in 2025, 3,288 of them with Medicare as their primary coverage. Every figure on this page is built on those 3,288 and nothing outside them.
1,048 of the 3,288 Medicare patients also carry Medicaid, 31.9% of the panel. That share puts the top advanced primary care management tier, G0558 at $117.24 a month, in reach for a large part of the panel, and it is the single best-paying monthly code on this page.
Blood-pressure control is 62.61% and diabetes poor control is 24.56%, down from 29.51% in 2021; statin therapy is 79.21%. Those are the measures continuous readings and a documented monthly touch move, and they are the measures the health center reports to HRSA every year.
Between 2021 and 2025 the share of patients with no coverage fell by more than half as the center connected patients to Medicaid, Marketplace and Medicare. A health center already reaching hard-to-reach patients is the right one to be paid for the month between visits.
One structural fact completes the picture: there is no remote patient monitoring, chronic care management or advanced primary care management program in place today. Telehealth is video visits only, and no care-manager or monitoring role is on the careers page. The 5,410 patients with hypertension and the 2,671 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 Middle Georgia acute-care hospitals its patients use can now be followed through a billable two-week window, next to the standard monthly stack. These short-window codes add a post-discharge layer to the monthly stack, and both are already inside the forecast on this page.
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 with two or more chronic conditions, $117.24. With 31.9% of the Medicare panel dually eligible, the tier mix on this forecast blends to about $61.49 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 Middle Georgia acute-care hospitals; 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 3,288 Medicare patients, all of them in scope from month one, its adult-medicine clinicians plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the eClinicalWorks integration. Transitional care and behavioral health integration are named but not in these numbers.
After denials and coinsurance bad debt; $829,992 in Year 1 and $1,606,649 in Year 2.
42.39% of net reimbursement after CoachCare's fees: 41.56% in Year 1, 42.82% in Year 2.
Unique patients in active remote care at month 24 (792 at month 12), as the program reaches full census when RPM saturates in month 16.
RPM 748 + CCM 395 + APCM 345 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $1,182,356 | $677,990 | $504,366 |
| CCM | $834,415 | $425,236 | $409,179 |
| APCM | $419,870 | $239,050 | $180,820 |
| Implementation, eClinicalWorks integration, outreach | — | $61,417 | −$61,417 |
| 24-month total | $2,436,642 | $1,403,693 | $1,032,948 |
| 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 | $829,992 | $485,053 | $344,939 | 41.56% |
| Year 2 | $1,606,649 | $918,640 | $688,009 | 42.82% |
| 24 months | $2,436,642 | $1,403,693 | $1,032,948 | 42.39% |
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 $1,211,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 16,444 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 345 enrollments in month 6 and CCM its ceiling of 395 in month 10, but RPM does not reach its ceiling of 748 until month 16. The program is large enough that the binding constraint in year one is enrollment pace, clinician referrals and the CoachCare-funded specialist, not the eligibility ceiling. From month 16 the census holds at 1,488 program enrollments, 970 patients. The first 90 days, modeled: 64 new enrollments in month 1, 106 in month 2, 148 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 748 | 3,288 in scope × 65% eligible (2,137) × 35% acceptance | Month 16 |
| CCM | 395 | 3,288 × 40% (1,315) × 30% | Month 10 |
| APCM | 345 | 3,288 × 35% (1,151) × 30% | Month 6 |
| At month 24 | 1,488 | Program enrollments = 970 patients | — |
The ceilings above are reached with one CoachCare-funded on-site enrollment specialist working across the health center's sites. Without that specialist the same ceilings are not reached until months 24, 15 and 8 instead of 16, 10 and 6, and 24-month net reimbursement falls to $2,019,703. The specialist cannot raise a ceiling. Reaching it months sooner is worth $416,939 over 24 months, and it is CoachCare's payroll. A second specialist reaches the ceilings by month 12 and lifts the forecast to $2,629,855.
The panel on this page is the full UDS Medicare count, 3,288 patients, priced at the national amounts a health center is paid. Most of those patients are in Medicare Advantage plans, which reimburse these code families as a floor at least equal to the Medicare amount, with terms set contract by contract. Counting only traditional Medicare, the same program is $1,126,144 of 24-month net reimbursement, the conservative floor. Reconciling the traditional-versus-Advantage split by payer, and which plans the dually eligible patients carry, is the first discovery item and the number that moves this forecast most.
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 the eClinicalWorks billing module; 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 the eClinicalWorks billing module 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 a Middle Georgia acute-care hospital 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 for a panel where 95 percent of patients live at or below the poverty line, spread across eight sites in Macon and Warner Robins, is not the one that works in a suburb of retirees. 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 matters on a low-income panel.
Device instructions and call scripts are written plainly and in the patient's own language where needed. A monthly documented touch reaches people an office calendar does not, in terms they can act on.
The 1,048 dually eligible patients are Qualified Medicare Beneficiaries: they owe no Medicare cost-sharing, so there is no copay to explain and no bill to chase. Enrollment across the dual panel is frictionless, which is also where APCM pays the most.
The CoachCare-funded specialist works enrollment across the Macon and Warner Robins sites, including at the on-site 340B pharmacies where chronic-disease patients already come for refills. Consent, device setup and the first reading happen face to face.
Lists come from the hypertension and diabetes registries first, then payer, so the Medicare-billable patients are worked first and no eligible patient is missed across the eight sites.
Most of the health center's clinicians are nurse practitioners and physician assistants. The care-management codes are built for general supervision, so the team as it stands today, and the roles it is recruiting for now, fit the way the codes work.
The health center serves Macon and Warner Robins from eight clinical sites, two on-site 340B pharmacies and school-based clinics. Middle Georgia carries a heavy chronic-disease burden and a Medicare population most of which is in Medicare Advantage, in a state that did not expand Medicaid.
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 $1,254,285 of the $2,436,642 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $21,233 of the $133,731 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, physician assistants 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 holiday calendar loaded into the outreach rules; 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 across the Macon and Warner Robins sites; the post-discharge cadence live from day one.
APCM fills in month 6, CCM in month 10 and RPM in month 16; monthly scorecard to the executive team, with the blood-pressure control and diabetes measures the health center reports to HRSA each year.
Re-run eligibility against the payer reconciliation, bring transitional care to every discharge, and add behavioral health integration as the next arm alongside the health center's own behavioral-health team.
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.
This is the health center's service line: its patients, its protocols, its claims and its revenue, billed under its own NPIs. CoachCare is the engine underneath it, and the reason the program stands up in months instead of years.
Cellular cuffs, scales and glucometers, the monitoring platform, the care managers, device logistics and billing-ready claims come from a single vendor, not a patchwork the health center has to assemble and manage. One contract, one accountable partner.
CoachCare runs remote care for more than 500,000 patients across 1,000-plus implementations, on the general-supervision, APP-led model a health center already uses. The program fits the way First Choice Primary Care is staffed today, and the enrollment labor is ours.
Enrollment flags and orders are placed in the eClinicalWorks workflow; vitals, care plans and enrollment status post to the chart every month; claims are created with the care-management codes and the health center's own billing team files them. Clinicians stay in the chart they already use.
No upfront capital and no new health-center headcount. The health center bills under its own NPIs and keeps the revenue; CoachCare supplies a named care pod carrying about 160 patients each, against the roughly 300-to-one a self-built program runs. Enrollment happens on site because telephonic outreach converts at about eight percent, and chronic-disease patients enroll best face to face.
Continuous readings and a documented monthly touch are what move blood-pressure control and diabetes control, the UDS measures First Choice Primary Care reports to HRSA every year, and what produce the 80.7 avoided hospitalizations in the Value Analysis. The same program that bills the codes defends the numbers HRSA grades.