Lawmakers target chronic care patient copays, but would physicians earn more?

Medicare could save money while expanding services to beneficiaries if Congress eliminates out-of-pocket costs that beneficiaries pay for chronic care management (CCM) treatment, advocates say.

This week, lawmakers introduced the Chronic Care Management Improvement Act of 2026, which would waive the 20% coinsurance requirement currently charged to Medicare patients who receive CCM services. The plan has backing from dozens of medical groups along with bipartisan support in Congress. Research has shown CCM can benefit patients; if more patients used it, it could become a source of more revenue, but also more work, for physicians and other clinicians.

“Removing barriers to chronic care management is key to lowering health care costs and delivering better results for seniors,” Rep. Suzan DelBene (D-Washington) said in a news release. “Chronic health conditions account for 90% of national health care spending, yet too few seniors are receiving these incredibly impactful services. Dropping cost-sharing requirements would increase access to these services for more seniors.” 

“The Chronic Care Management Improvement Act aims to allow seniors to access important services to manage their health, free of co-pays,” Rep. Mike Kelly (R-Pennsylvania) said in the news release. “This bill helps doctors manage patient health behind the scenes, an essential tool in the preventative care toolbox.”

Good care, but will patients pay?

CCM services cover a range of behind-the-scenes care coordination activities, including medication reconciliation, comprehensive care planning, 24/7 provider access, coordination with home and community-based providers, and management of care transitions. Medicare has reimbursed providers separately for these services since 2015, when the U.S. Centers for Medicare and Medicaid Services (CMS) established a dedicated billing code under the Medicare Physician Fee Schedule.

Despite that coverage, utilization has remained low. More than 22 million beneficiaries are eligible for treatments for at least two chronic conditions, but only 882,000, or approximately 4%, have received CCM services. The lawmakers cited a 2022 analysis of 2019 data compiled by the U.S. Department of Health and Human Services and NORC at the University of Chicago.

Currently, the cost-sharing is a financial burden and a source of confusion. Coinsurance typically amounts to about $12 per month, but patients often receive bills without having had office visits. Under Medicare rules, physicians and other clinicians are required to obtain patient consent before delivering CCM services and must make a good-faith effort to collect any applicable cost-sharing. It’s a dynamic that can discourage participation on both sides, according to the legislators.

Medicare savings in the long run

Eliminating cost-sharing would encourage both patients and providers to engage more fully in coordinated care, Jerry Penso, M.D., M.B.A., president and CEO of AMGA, the American Medical Group Association, said in a statement.

“Chronically ill patients face numerous challenges and are constantly interfacing with the health care system,” Penso said. “Removing cost-sharing requirements from CCM services will encourage patients and providers to engage in the care coordination necessary to manage complex health conditions in the most appropriate setting for the patient.”

A 2017 analysis by Mathematica, a research and data analytics firm, found that Medicare beneficiaries receiving CCM services had significantly lower overall expenditures than those who did not. After 12 months, spending fell by $28 per beneficiary per month compared with nonrecipients. That figure rose to $72 per beneficiary per month when the analysis was extended to 18 months.

Effects on physician pay

The representatives’ announcement did not include exact data on potential financial effects for physicians.

The American Academy of Family Physicians (AAFP) has published resources for doctors to consider using with patients who need the care.

“The AAFP’s advocacy efforts helped pave the way for Medicare payment for CCM services, giving family physicians an opportunity to be paid for the many services they provide outside traditional face-to-face office visits,” said the Academy’s webpage with CCMS resources. “The AAFP believes that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.”

Research consistently shows that chronic care management, or CCM, delivers meaningful health benefits for patients with multiple chronic conditions. Overall savings happen largely by reducing hospitalizations and emergency room visits. One Kansas family medicine practice found that regular monthly check-in calls helped keep patients out of the emergency room, including those who previously visited for non-clinical reasons such as running out of medication, according to a 2024 KFF analysis republished in the Journal of Health Economics and Outcomes Research. A 2025 study published in the American Journal of Public Health found statistically significant improvements in controlling Type 2 diabetes and blood pressure among Medicare patients who participated in an expanded CCM intervention.

For physicians, however, the financial picture is more complicated. Medicare pays an average of $62 per patient per month for 20 minutes of CCM work. About 4,500 physicians received at least $100,000 each in CCM reimbursements in 2021, per the KFF analysis, suggesting real income potential for practices that implement the program effectively.

Yet the upfront costs and administrative demands can offset those gains. Practices must invest in staffing, documentation systems, and electronic health record integration before reimbursements begin flowing. Third-party companies that manage CCM on a practice's behalf can claim more than half of Medicare's payment.

Physicians can bill for services, along with clinical nurse specialists, nurse practitioners, physician assistants, and certified nurse midwives, so the American Journal of Public Health study refers to the provider-nurse duo. That study identified dependence on the provider-nurse duo as a structural weakness, noting that documentation demands and staffing shortages make the traditional two-person model unsustainable.

Expanding the care team to include a community health worker and pharmacist, funded through CCM reimbursements, reduced direct provider workload while achieving a Medicare reimbursement rate of 85.5%. That suggests a more fiscally durable model for independent practices willing to restructure their approach, according to the study.

Additional supporters

Along with AAFP and AMGA, DelBene and Kelly’s news release listed other supporting organizations: Alzheimer's Association and the Alzheimer's Impact Movement, American Association of Nurse Practitioners, American Association of Psychiatric Pharmacists, AARP, American College of Clinical Pharmacy, American College of Lifestyle Medicine, American College of Osteopathic Family Physicians, American College of Physicians, American College of Rheumatology, American Diabetes Association, American Geriatrics Society, American Hospital Association, American Medical Association, American Osteopathic Association, American Psychiatric Association, American Society of Health-System Pharmacists, America's Essential Hospitals, America’s Physician Groups, Association of American Medical Colleges, Connected Health Initiative (CHI), Association for Competitive Technology (ACT), Cadence, Healthcare Leadership Council, Health Care Transformation Task Force, Mental Health America, Medical Group Management Association, National Alliance on Mental Illness, National Association of ACOs, National Kidney Foundation, National Patient Advocate Foundation, National Rural Health Association, Partnership to Fight Chronic Disease, Premier Inc., Primary Care Collaborative, Primary Care Development Corporation, Remote Monitoring Leadership Council, TapestryHealth, and The Alliance for Connected Care.