Half of this health center's Medicare patients are dually eligible. 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 the dual mix makes the monthly code worth more here than almost anywhere. The panel is small and it fills in seven months. The people to run it are ours. This is the 24-month plan, inside Veradigm, with CoachCare staffing the program.
Two counts, two jobs. 226 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 347 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $294,992 of the $689,514 is the health center's after CoachCare's fees.
A health center that has served Rockland County for more than thirty years, grew into behavioral health, fertility care and a mobile medical unit, sees patients in Yiddish, Hebrew, Spanish and Creole, cut diabetes poor control from 37.88% to 23.46% in five years and lifted depression screening from 19.74% to 62.73% over the same period. The work between visits already happens here. What it does not have yet is a Medicare revenue line under it.
The health center reported 18,211 patients in 2025, 2,103 of them 65 or older and 766 with Medicare as their primary coverage. Every figure on this page is built on those 766 and nothing outside them.
381 of the 766 Medicare patients also carry Medicaid. That share is what 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 why the monthly code is worth more here than at most practices.
Blood-pressure control is 64.01% and diabetes poor control is 23.46%, down from 37.88% in 2021. Statin therapy is 74.21%. Those are the measures continuous readings and a documented monthly touch move, and they are the measures the health center reports every year.
Between 2024 and 2025 the number of patients receiving support services rose more than fourfold. A health center that already reaches patients outside the exam room in their own language 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 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 1,706 patients with hypertension and the 1,172 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 two acute-care hospitals in Rockland County can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $65,253 of reimbursement over 24 months before denials and bad debt, about 9.5% 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. With 49.7% of the Medicare panel dually eligible, the tier mix on this forecast blends to $70.37 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 Veradigm 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 the two Rockland County 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 766 Medicare patients, all of them in scope from month one, eight internists, physician assistants and nurse practitioners plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the Veradigm integration. Transitional care, behavioral health integration and New York Medicaid are not in these numbers.
After denials and coinsurance bad debt; $302,940 in Year 1 and $386,574 in Year 2.
42.78% of net reimbursement after CoachCare's fees: 41.60% in Year 1, 43.71% 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 7.
RPM 174 + CCM 92 + APCM 80 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $348,465 | $195,634 | $152,831 |
| CCM | $221,213 | $110,083 | $111,131 |
| APCM | $119,836 | $66,756 | $53,079 |
| Implementation, Veradigm integration, outreach | — | $22,049 | −$22,049 |
| 24-month total | $689,514 | $394,522 | $294,992 |
| 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 | $302,940 | $176,911 | $126,029 | 41.60% |
| Year 2 | $386,574 | $217,611 | $168,963 | 43.71% |
| 24 months | $689,514 | $394,522 | $294,992 | 42.78% |
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 $358,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 4,622 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 80 enrollments in month 3, CCM its ceiling of 92 in month 5, and RPM its ceiling of 174 in month 7. From there the census holds at 347 program enrollments, 226 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, 79 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 174 | 766 in scope × 65% eligible (498) × 35% acceptance | Month 7 |
| CCM | 92 | 766 × 40% (306) × 30% | Month 5 |
| APCM | 80 | 766 × 35% (268) × 30% | Month 3 |
| At month 24 | 347 | Program enrollments = 226 patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working the Monsey campus, including Sunday clinic hours. Without that specialist the same ceilings are reached in months 14, 10 and 6 instead of 7, 5 and 3, and 24-month net reimbursement falls to $597,917. The specialist cannot raise a ceiling. Reaching it months sooner is worth $91,597 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 reported 2,103 patients aged 65 and over against 766 with Medicare as primary coverage, and reconciling those two counts by payer is the first discovery item. The same program on the 2024 Medicare count of 1,013 patients is $883,090 of 24-month net reimbursement; on every patient 65 and over it is $1,577,215. The second lever is the New York Medicaid remote-monitoring rail below, where most of the health center's chronic-disease volume sits.
Seventy percent of the health center's patients are on Medicaid, and most of its 1,706 hypertensive and 1,172 diabetic patients are among them. New York Medicaid has paid for remote physiologic monitoring since January 1, 2025, with managed-care plans required to follow since March 1, 2025, and added the 10-minute management code on January 1, 2026. A health center on the state's APG methodology can bill these codes, and this health center has been on the APG list since 2014.
New York State Medicaid physician fee schedule, July 1, 2026. New York Medicaid does not pay for chronic care management, advanced primary care management, transitional care management or behavioral health integration; those are Medicare-only rails here.
The health center runs on Veradigm, and this plan is priced on CoachCare's Veradigm integration. Enrollment flags and orders are placed inside the Veradigm workflow; monitored vitals, Evidence of Care documents, care plans and enrollment status post to the chart every month; claims are created automatically in Veradigm Practice Management; 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 Veradigm, 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 Veradigm chart. One chart, no second system for clinicians.
Claims are created automatically in Veradigm Practice Management 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 Rockland County 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 in Monsey is not the one that works in a suburb of retirees. The median age here is 16, four in five households speak a language other than English at home, and the week has a shape the program has to respect. 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.
Device instructions and call scripts in the four languages the health center already serves, matched to the language on the patient's chart. A monthly documented touch in the patient's own language reaches people an office calendar does not.
No outbound calls and no non-urgent alert follow-up from Friday afternoon through Saturday night or on Jewish holidays. The emergent pathway runs regardless: a critical value on the Sabbath is still a 911 call with the patient on the line.
The health center is open on Sunday, and the on-site enrollment specialist works it. Consent, device setup and the first reading happen face to face, on the day many working families come in.
In a panel with a median age of 16, an age-based list finds almost no one. Lists come from the hypertension and diabetes registries first, then payer, so the Medicare rail and the Medicaid rail each get the patients who belong on them.
Three of the eight referring clinicians are physician assistants or nurse practitioners. 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 Monsey, Spring Valley, Suffern and the surrounding Rockland villages from its main campus, its behavioral-health division, a fertility center and a mobile medical unit. The county's Medicare population is older, poorer in its pockets and more often dually eligible than its median income suggests.
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 $341,049 of the $689,514 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $5,518 of the $38,690 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 Veradigm integration runs in parallel with onboarding, and the first enrollments follow the first orders.
Veradigm 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 Sabbath and 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 the Monsey campus, Sundays included; the post-discharge cadence live from day one.
APCM fills in month 3, CCM in month 5, RPM in month 7; monthly scorecard to the executive team, with the blood-pressure control and diabetes measures the health center reports each year.
Re-run eligibility against the payer reconciliation, size and launch the New York 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 division.
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.
Six reasons this fits Monsey Health Center specifically, not remote care in general.
Individual care-management codes go on the health-center claim in addition to the encounter, filed by the center's own reimbursement team. The 2026 change that unbundled those codes is the reason the forecast on this page exists, and the program is built around it.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The health center inherits a running program at a 42.78% margin, and the 2.2 FTE-years of work in the forecast never touch its staffing plan.
The center already coordinates chronic care for its members. This plan adds cellular devices, documented monthly clinical management and Medicare billing to that shape of care, and sets a working rule for how the programs share a dually eligible member. Where the care team stands today is the first discovery question.
CoachCare integrates bi-directionally with Veradigm: eligibility and orders leave the EHR, and vitals, care documentation and claim-ready charges come back into it. One chart for clinicians, one workflow for the reimbursement team, no second system.
For the dually eligible slice the coinsurance objection disappears, so enrollment leads with the care. A top-tier APCM code is documented correctly every month, and the QMB and Medicaid crossover is handled on the claim so nothing is billed to a patient who cannot be billed.
Fees are per active patient per month, with no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid. The forecast, Disclosures and workbook behind this page are yours to keep either way.