Nearly every one of this health center's Medicare patients is dually eligible, and most of them are Qualified Medicare Beneficiaries. Since last October, Medicare pays a health center for the month of care between visits as its own codes, and that dual mix makes the monthly advanced primary care code worth more here than almost anywhere. The health center is already in a Medicare ACO whose shared savings turn on the two measures this program moves: blood-pressure control and diabetes control. The panel is small and it fills in eight months. The people to run it are ours. This is the 24-month plan, inside athenaOne, with CoachCare staffing the program.
Two counts, two jobs. 277 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 425 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $362,317 of the $854,737 is the health center's after CoachCare's fees.
A community health center that has served Tallahassee and rural Gadsden County since 1974, grew from a church basement in Frenchtown into five sites, an in-house pharmacy, a Ryan White HIV program and school-based clinics, and reaches a largely Black, largely uninsured, heavily dual-eligible population. On the one chronic-care measure with a clear protocol behind it, statin therapy, it ranks in the top quartile of health centers nationally. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 9,585 patients in 2025, 884 of them 65 or older and 940 with Medicare as their primary coverage. Every figure on this page is built on those 940 and nothing outside them.
878 of the 940 Medicare patients also carry Medicaid, and about two-thirds of the area's dual-eligibles are Qualified Medicare Beneficiaries. That is what puts the top advanced primary care management tier, G0558 at $116.73 a month, in reach for most of the panel, and it is why the monthly code is worth more here than at almost any practice.
Blood-pressure control is 51.86% and diabetes poor control is 31.68%, the two measures the health center ranks lowest on. Statin therapy is 85.29%, among the highest. Continuous readings and a documented monthly touch move the first two, and they are measures the health center reports every year.
Since January 2025 the health center has shared in Medicare savings through VitaSavings Florida and draws up-front Advance Investment capital to build care infrastructure. The measures that accountable-care agreement scores are the measures this program moves.
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 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 1,452 patients with hypertension and the 726 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, 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 CY2026 MAC-locality amounts; a health center bills these codes at the national amounts, which run slightly higher, so the numbers here are the conservative ones.
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 two acute-care hospitals in Tallahassee can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $74,867 of reimbursement over 24 months before denials and bad debt, about 8.8% of net reimbursement.
Advanced primary care management pays a flat monthly amount by tier: $16.38, $53.45 and, for a patient who is a Qualified Medicare Beneficiary, $116.73. With 93% of the Medicare panel dually eligible and most of them QMB, the tier mix on this forecast blends to $87.71 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 athenaOne 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, MAC-locality non-facility | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $21.12 setup · $50.00/mo | Hypertension and diabetes cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.12 + $41.22 add'l · $25.73 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $65.97 + $50.16 add'l | Two or more chronic conditions; the longitudinal wrapper |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.38 · $53.45 · $116.73/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 two Tallahassee 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 non-facility rates at the Florida locality this health center sits in. A health center bills these codes at the national amounts, which run a fraction of a percent higher, in addition to the PPS encounter; the locality amounts here are the conservative basis every figure on this page is priced on.
The health center joined VitaSavings Florida, a Medicare Shared Savings Program ACO built for health centers, in January 2025: upside-only, and drawing Advance Investment Payments, the up-front capital CMS pays to build care infrastructure in underserved areas. Shared savings turn on quality scores and avoidable hospital use. Both are exactly what remote monitoring and chronic care management move, and CoachCare is the infrastructure that capital is meant to buy.
The two measures the health center ranks lowest on, blood-pressure control at 51.86% and diabetes poor control at 31.68%, are also the two that a monthly documented touch and continuous readings move, and both are ACO quality points. Statin therapy at 85.29% shows the team executes when a protocol is in place; remote monitoring is that protocol for blood pressure and glucose.
Advance Investment Payments exist to stand up care management, data and staffing in a health center that could not otherwise fund it. A consented, monitored, monthly-managed panel is that infrastructure. This service line builds it without the health center hiring, and it earns fee-for-service revenue while it does.
The care-management revenue on this page is fee-for-service and additive; it does not reduce shared savings, it helps earn them. Three rails run on the same panel: per-code fee-for-service, the basis on this page; the shared-savings overlay through the ACO, upside-only; and Medicare Advantage for the majority of the panel in MA plans, which each plan's contract governs.
A 24-month forecast for the RPM + CCM + APCM stack: the health center's own 940 Medicare patients, all of them in scope from month one, eight adult-medicine clinicians plus CoachCare's enrollment outreach, the CY2026 MAC-locality amounts, and the athenaOne integration. Transitional care, behavioral health integration and Florida Medicaid are not in these numbers.
After denials and coinsurance bad debt; $366,624 in Year 1 and $488,112 in Year 2.
42.39% of net reimbursement after CoachCare's fees: 41.59% in Year 1, 42.99% in Year 2.
Unique patients in active remote care at month 24, the same count as at month 12, because the panel is full by month 8.
RPM 214 + CCM 113 + APCM 99 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $406,817 | $232,939 | $173,878 |
| CCM | $266,206 | $132,990 | $133,216 |
| APCM | $181,713 | $103,033 | $78,680 |
| Implementation, athenaOne integration, outreach | — | $23,458 | −$23,458 |
| 24-month total | $854,737 | $492,420 | $362,317 |
| 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 | $366,624 | $214,150 | $152,474 | 41.59% |
| Year 2 | $488,112 | $278,270 | $209,843 | 42.99% |
| 24 months | $854,737 | $492,420 | $362,317 | 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 $426,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 5,539 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 99 enrollments in month 4, CCM its ceiling of 113 in month 6, and RPM its ceiling of 214 in month 8. From there the census holds at 425 program enrollments, 277 patients; month 12 and month 24 are the same number. 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, 66 in month 2, 92 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 214 | 940 in scope × 65% eligible (611) × 35% acceptance | Month 8 |
| CCM | 113 | 940 × 40% (376) × 30% | Month 6 |
| APCM | 99 | 940 × 35% (329) × 30% | Month 4 |
| At month 24 | 425 | Program enrollments = 277 patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working across the health center's sites. Without that specialist the same ceilings are reached in months 17, 11 and 6 instead of 8, 6 and 4, and 24-month net reimbursement falls to $716,242. The specialist cannot raise a ceiling. Reaching it months sooner is worth $138,495 over 24 months, and it is CoachCare's payroll.
Because every program fills inside the first year, the number that moves this forecast is the Medicare panel itself. The health center's Medicare-primary count has run between 856 and 1,278 across the last five reporting years, and reconciling the current panel by payer is the first discovery item. The same program on the lower count of 856 is $786,192 of 24-month net reimbursement; on the five-year peak of 1,278 it is $1,112,188. The second lever is the Florida Medicaid remote-monitoring rail below, where most of the health center's chronic-disease volume sits.
Forty percent of the health center's patients are on Medicaid, and most of its 1,452 hypertensive and 726 diabetic patients are among them. Florida Medicaid covers remote physiologic monitoring and chronic care management on its practitioner fee schedule, which means the same cellular devices and the same monthly workflow reach a second, larger slice of the panel.
Florida Medicaid practitioner fee schedule, effective October 1, 2025. Florida Medicaid does not list advanced primary care management or transitional care management; those are Medicare-only rails here. Behavioral health integration is covered on both.
The health center runs on athenahealth, and this plan is priced on CoachCare's athenaOne integration. Enrollment flags and orders are placed inside the athenaOne workflow; monitored vitals, Evidence of Care documents, care plans and enrollment status post to the chart every month; claims are created automatically in athenaOne 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 athenaOne, 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 athenaOne chart. One chart, no second system for clinicians.
Claims are created automatically in athenaOne 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 either of the two acute-care hospitals in Tallahassee 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 this health center is not the one that works in a suburb of retirees. Two-thirds of the panel is Black, a third is uninsured, many patients do not have reliable home internet, and the service area runs from urban Frenchtown to rural Gadsden County. Five 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 for a panel where connectivity cannot be assumed.
For patients in rural Gadsden County, a reading taken at home and reviewed the same day is care that would otherwise wait for the next trip into a clinic. The month between visits is covered without anyone driving it.
Device instructions and call scripts in English and Spanish, matched to the language on the patient's chart, for a service area with a growing Hispanic share. A monthly documented touch in the patient's own language reaches people an office calendar does not.
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. The dual-eligible panel is worked first, because that is where the monthly code pays the most.
Six of the eight referring clinicians are nurse practitioners or physician assistants, and the diabetes educator is a clinical pharmacist. The care-management codes are built for general supervision, so the team as it stands today fits the way the codes work.
Patient materials are written at a low reading level, enrollment respects the sliding-fee and uninsured reality of the panel, and the program is explained as part of the health center's own care, not a vendor's.
The health center serves Tallahassee in Leon County and Havana in Gadsden County from five clinical sites, an in-house pharmacy and two school-based clinics. Its Medicare panel is heavily dual-eligible and increasingly enrolled in Medicare Advantage.
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 on the same MAC-locality 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 $447,919 of the $854,737 in 24-month net reimbursement. Their own amounts move by a point or less through conversion-factor and RVU churn, so $6,971 of the $43,894 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. The same logic already runs through the health center's accountable-care agreement. A consented, documented, monthly-managed panel with 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 CY2026 MAC-locality 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. The forecast above is priced on the MAC-locality amounts, which run a fraction of a percent below these; the two bases do not reconcile to the dollar, by design, and both move in the same direction.
| 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 athenaOne integration runs in parallel with onboarding, and the first enrollments follow the first orders.
athenaOne 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 across the sites; the post-discharge cadence live from day one.
APCM fills in month 4, CCM in month 6, RPM in month 8; monthly scorecard to the executive team, with the blood-pressure control and diabetes measures the health center reports each year and its ACO scores.
Re-run eligibility against the payer reconciliation, size and launch the Florida Medicaid remote-monitoring 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 and HIV programs.
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.