YourTown Health has been accountable for the total cost of its Medicare patients' care since 2013, at two-sided risk. Since last October, Medicare pays a health center for the month of care between visits as its own codes, at national amounts, on top of every visit, and it is the same work that moves a shared-savings settlement. The Medicare panel is about 1,679 patients and it fills by the middle of year two. The people to run it are ours. This is the 24-month plan, inside eClinicalWorks, with CoachCare staffing the program.
Two counts, two jobs. 495 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 760 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $552,268 of the $1,294,294 is the health center's after CoachCare's fees.
A Section 330 community health center serving the counties from the south-metro-Atlanta edge to rural Meriwether, Lamar and Pike since 1978, with its own 340B pharmacy and its own dental and behavioral-health services. It screens more than nine in ten of its patients for depression with a follow-up plan and keeps most of its cardiovascular-risk patients on a statin. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 8,925 patients in 2025, 1,819 of them 65 or older and 1,679 with Medicare as their primary coverage. Every figure on this page is built on those 1,679 Medicare patients and nothing outside them.
The health center has taken part in an Enhanced Medicare Shared Savings Program accountable care organization since 2013, at full two-sided risk, which means it is already accountable for the total cost of its attributed Medicare patients' care. The one lever that moves total cost is the one this plan builds.
Blood-pressure control is 62.2%, down from 66.9% two years ago, and diabetes poor control sits in the bottom national quartile at 37.5%. 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.
An in-house 340B community pharmacy and depression screening with follow-up at 93%, in the top national quartile. A health center that already reaches patients outside the exam room 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 Medicare Part B claims, and no care-manager or monitoring role is on its careers page. CMS suppresses claim lines under eleven beneficiaries, and care management billed on the health-center claim would not appear in that file regardless. The 2,686 patients with hypertension and the 1,428 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 a new monthly payment for the primary-care panel itself.
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 in the counties the health center serves can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $120,549 of reimbursement over 24 months before denials and bad debt, about 9.3% 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. About 22.7% of this Medicare panel is dually eligible, so the tier mix on this forecast blends to $57.68 per patient-month. It is a monthly payment for managing the panel the health center already sees, and 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 for the primary-care panel itself.
| 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 the six counties; 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 1,679 Medicare patients, all of them in scope from month one, eight physicians, physician assistants and nurse practitioners plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the eClinicalWorks integration. Transitional care and behavioral health integration are not in these numbers, and neither is any shared-savings dollar; the forecast is fee-for-service only.
After denials and coinsurance bad debt; $471,365 in Year 1 and $822,929 in Year 2.
42.67% of net reimbursement after CoachCare's fees: 41.51% in Year 1, 43.33% in Year 2.
Unique patients in active remote care at month 24. The panel fills through month 14, early in year two, and holds from there.
RPM 382 + CCM 202 + APCM 176 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $644,948 | $365,774 | $279,174 |
| CCM | $444,136 | $223,678 | $220,457 |
| APCM | $205,211 | $115,339 | $89,872 |
| Implementation, eClinicalWorks integration, outreach | — | $37,235 | −$37,235 |
| 24-month total | $1,294,294 | $742,026 | $552,268 |
| 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 | $471,365 | $275,693 | $195,672 | 41.51% |
| Year 2 | $822,929 | $466,333 | $356,596 | 43.33% |
| 24 months | $1,294,294 | $742,026 | $552,268 | 42.67% |
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 $661,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 8,870 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 176 enrollments in month 5, CCM its ceiling of 202 in month 8, and RPM its ceiling of 382 in month 14, early in year two. From there the census holds at 760 program enrollments, 495 patients. The binding constraint on this forecast is the size of the Medicare panel, not enrollment capacity and not clinician count. The first 90 days, modeled: 40 new enrollments in month 1, 67 in month 2, 93 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 382 | 1,679 in scope × 65% eligible (1,091) × 35% acceptance | Month 14 |
| CCM | 202 | 1,679 × 40% (672) × 30% | Month 8 |
| APCM | 176 | 1,679 × 35% (588) × 30% | Month 5 |
| At month 24 | 760 | Program enrollments = 495 patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist. Without that specialist the RPM panel never fills inside 24 months: it stalls at about 300 of its 382 ceiling, and 24-month net reimbursement falls to $870,473. The specialist cannot raise a ceiling. Reaching it at all, and reaching the other two programs months sooner, is worth $423,821 over 24 months, and it is CoachCare's payroll, not the health center's.
Because the programs fill, the number that moves this forecast is the Medicare panel itself. The health center reported 1,819 patients aged 65 and over against 1,679 with Medicare as primary coverage, and reconciling those two counts by payer is the first discovery item. The same program across all 1,819 patients aged 65 and over is $1,373,715 of 24-month net reimbursement; at the health center's 2023 Medicare count of 2,545 it is $1,715,840. The second lever is the value-model performance in the next section, where the same managed panel earns a shared-savings settlement.
YourTown Health has taken part in an Enhanced, two-sided-risk Medicare Shared Savings Program accountable care organization since 2013. Under two-sided risk the health center is accountable for the total cost of its attributed Medicare patients' care. The lever that moves total cost, documented continuous management of the month between visits, is exactly what this service line builds, and it bills as its own fee-for-service revenue while it does it.
The health center's accountable care organization is not in the Primary Care Flex model, so the care-management codes are not folded into a monthly prospective payment. Chronic care management, advanced primary care management and remote monitoring each pay per claim at the national amounts. The service line is margin-positive on its own, before any shared-savings dollar.
Attribution to the organization runs on primary-care service codes, so a consented panel under documented monthly management stays attributed, and the continuous readings and the avoided admissions are what move the cost and quality figures a two-sided settlement is scored on. The work that bills is the work that performs.
How many of the health center's Medicare patients are attributed to the organization, and where its benchmark sits, are the two numbers that size the value-model half. So is how the dominant Medicare Advantage plans handle the care-management code families. Those are the first items for the working session.
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 practice-management system; 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 practice-management system 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 one of the acute-care hospitals in the counties the health center serves 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 six Georgia counties, from the south-metro-Atlanta edge to rural Meriwether, Lamar and Pike, is not the one that works in a single affluent suburb. More than one patient in five speaks English less than very well, and some live the better part of an hour from the nearest site. 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 most in the rural counties.
Device instructions and call scripts in both languages, matched to the language on the patient's chart. More than one patient in five here speaks English less than very well, so a monthly documented touch in the patient's own language reaches people an office calendar does not.
Across a footprint that runs from the metro edge into rural West Georgia, a daily reading and a monthly call reach patients who are otherwise seen only when they can make the drive. The between-visit layer is where distance stops being the barrier.
The on-site enrollment specialist and the device workflow run the same way at every site, from the Palmetto campus to the rural clinics, so a patient enrolls, gets a device and takes a first reading where they already come for care.
Lists come from the hypertension and diabetes registries first, then payer, so the Medicare panel gets the patients who belong on it and the enrollment specialist works the highest-yield cohorts first.
Three of the eight referring clinicians are physician assistants or nurse practitioners. The care-management codes are built for general supervision, so the adult-medicine team is already organized the way the codes work.
The health center serves Fulton, Coweta, Carroll, Meriwether, Lamar and Pike from seven sites, half of them rural. Its patients are lower-income and more often uninsured than the metro-Atlanta averages suggest, and its Medicare population carries an unusually high Medicare Advantage share, which shapes how this plan is read.
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 $649,346 of the $1,294,294 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $11,318 of the $72,693 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 discharge trigger wired to the three-touch cadence across the county hospitals.
Advanced primary care management across the panel, chronic care management across the two-plus-condition cohort and RPM for the hypertension and diabetes cohorts; CoachCare's on-site enrollment specialist working across the seven sites; the post-discharge cadence live from day one.
APCM fills in month 5, CCM in month 8, RPM in month 14; 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, add behavioral health integration as the next arm alongside the health center's own behavioral-health service, and put the managed panel's cost and quality performance in front of the accountable care organization.
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.