What you are being offered
Someone at your doctor’s office asks whether you would like to enroll in a program, often shortened to CCM. A fair first question: what is chronic care management, and is it worth saying yes?
It is organized help from your primary care practice between visits. Someone keeps a written care plan current, checks in with you regularly and handles the tasks that pile up when you live with more than one long-term condition.
Medicare describes it as a service for people with two or more chronic conditions expected to last at least a year. Other plans may run similar programs under other names.
What the practice takes on
The treating practice decides the details. In general, it agrees to:
- Write a care plan covering your conditions, medications and goals, and give you a copy
- Check in on a regular schedule, commonly once a month by phone
- Review your medications and help with refills
- Follow up on test results and referrals
- Share information with your specialists, pharmacy and home health agency
- Help organize care after an emergency room visit or hospital stay
- Give you a way to reach the practice about urgent concerns outside office hours
The caller is usually a nurse or other staff member working under your clinician’s direction. Much of the work, such as calls to a pharmacy or specialist, happens when you are not on the phone.
What the consent conversation should cover
A practice needs your agreement before it enrolls you. Consent may be spoken or written. Before you give it, the practice should explain:
- What the service includes
- That you may be billed a share of the cost for each month you are enrolled
- That only one practice can provide it to you at a time
- That you can stop whenever you choose
If you find you were enrolled without that conversation, call the practice and ask for it.
Questions to ask before you say yes
- Who will call me, and will it be the same person each time?
- What might I owe each month? (Our insurance page lists questions for your plan.)
- What number do I call after hours, and who answers?
- Will my specialists and wound care team see the care plan?
- How do I stop if it is not helping?
How to get real use from the calls
A check-in can shrink to “How are you?” and “Fine.” Keep a running note between calls and have it by the phone:
- Readings you were asked to track
- Any new medicine, including one from another doctor or one bought over the counter
- Any fall, emergency room visit or urgent care visit
- Supplies or refills that are running low
- Appointments you could not get to, and why
Our guide to keeping an up-to-date medication list helps with the second item. If a call raises a medication question, the staff member takes it to the prescriber. Do not change how you take a medicine on your own.
What chronic care management is not
It is not an emergency line. For chest pain, trouble breathing, fainting or signs of a stroke, call 911.
It does not replace visits. Problems that need an examination still need a clinician in the room or on video.
It is not the nurse from your health plan. Many plans have their own case managers who call members. That is a separate program, so tell each one about the other.
Some practices pair it with home devices that send readings automatically. Our guide to what to expect from remote monitoring covers that.
If you also have a wound
Blood sugar, swelling and circulation all affect how skin repairs itself, which is why primary care and wound care belong together.
Tell the person who calls you that you are receiving wound care, and from whom. A diabetic foot ulcer, for example, should appear in the care plan along with the name of the wound clinician.
How Gateway can help
Gateway does not run these programs. Treating practices do. We arrange in-home primary care follow-up with partner clinicians in Greater St. Louis and the Metro East, and we keep your existing physician involved. Our page on chronic care management at home explains our part.
Call 314-325-0126 or send the request care form with a name and phone number only.
Common questions
Why did I get a bill in a month when I had no appointment?
Chronic care management is billed by the month, not by the visit. The charge reflects time staff spent on your care that month, including work you did not see. If a statement surprises you, ask the practice what was done. You can also ask to leave the program.
Can two of my doctors enroll me at the same time?
Under Medicare’s rules, only one practice at a time provides chronic care management for a patient. It is usually the primary care practice, though a specialist who manages most of your care sometimes takes that role. If a second office offers to enroll you, tell them you are already enrolled elsewhere.
What happens if I miss a monthly call?
Usually the staff member tries again or leaves a message with a number to call back. A missed call does not by itself end your enrollment. If phone calls are hard for you because of hearing, work hours or energy, say so. The practice may be able to change the time of day or include a family member.
How do I stop chronic care management?
Tell the practice, by phone or in writing, that you want to end your enrollment, and ask for the date it takes effect. You do not have to give a reason. Stopping the program does not end your relationship with the clinician, and you can still schedule regular visits as before.
Related pages
General information to help you talk with your own clinician. It is not medical advice, and the treating clinician makes every clinical decision. For a medical emergency, call 911.
Updated October 2026