In Del Norte County, 96 of every 100 Medicare patients are on Original Medicare. Since last October, Medicare pays a rural health clinic for the month of care between visits as its own codes, at national amounts, on top of every visit. The practice already runs extended hours and lifestyle medicine; what it does not have yet is a revenue line for the days between visits. The panel is small and it fills in seven months. The people to run it are ours. This is the 24-month plan, inside athenahealth, with CoachCare staffing the program.
Two counts, two jobs. 192 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 294 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $249,650 of the $581,542 is the practice's after CoachCare's fees.
A practice that opened in Crescent City in 2020, runs Sunday through Thursday until 8 pm, put primary care, dental, mental health, chiropractic, nutrition and physical therapy under one roof, opened a second site in 2025, and holds a 4.7-star patient rating across 134 reviews. Lifestyle medicine is the brand: blood pressure, weight and glucose, managed toward prevention rather than patched at the visit. The work between visits is already the point. What it does not have yet is a Medicare revenue line under it.
Medicare-certified as a rural health clinic at both Crescent City and Highland. That status is what lets the practice bill the care-management codes on this page at the national amounts, on top of the per-visit rate, the moment it enrolls a patient.
Del Norte County runs 4.26% Medicare Advantage. Almost every Medicare patient in Crescent City is fee-for-service, so the codes on this page pay per claim without a plan contract in the way. This is one of the lowest Medicare Advantage counties in California.
One in five Del Norte residents is 65 or older and one in five reports a disability, both above the California rate. Hypertension and diabetes are the daily work of a primary-care panel here, and they are exactly the conditions remote monitoring is built for.
Evening and Sunday hours, a hospitality model, and an athenahealth chart the whole team already runs. A practice that already organizes care around the patient 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 in evidence at the practice, on its site, its careers page or its claims. A rural health clinic's care-management billing rides an institutional claim, so it would not show in the physician fee-schedule data regardless, which is why the honest statement is that there is no program in evidence rather than a count of zero. The patients with hypertension and diabetes are seen a few times a year. Between those visits there is no revenue line yet.
Two things changed for a rural health clinic inside a year: how care management is billed, and what remote monitoring can bill for. Together they open a Medicare revenue line on a panel the practice already sees.
Through September 2025, a rural health clinic billed care management as one bundled code, G0511. Since October 2025, it bills chronic care management, remote monitoring and advanced primary care management as individual codes at the national non-facility amounts, in addition to the per-visit rate. Each service is paid on its own, every month it is delivered. The figures on this page are priced at the national amounts a rural health clinic 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 the community hospital three blocks away can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $53,761 of reimbursement over 24 months before denials and bad debt, about 9.2% 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 about a third of the panel dually eligible, the tier mix on this forecast blends to $65.33 per patient-month, paid for keeping the primary-care relationship active. 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 practice already knows, inside the athenahealth 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 relationship 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 community hospital three blocks away; 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 rural health clinic bills the care-management codes on in addition to the per-visit rate, and the basis every figure on this page is priced on.
A 24-month forecast for the RPM + CCM + APCM stack: the practice's own 650 Medicare patients, all of them in scope from month one, one physician and five nurse practitioners and physician assistants plus CoachCare's enrollment outreach, the national amounts a rural clinic is paid, and the athenahealth integration. Transitional care, behavioral health integration and Medi-Cal are not in these numbers.
After denials and coinsurance bad debt; $256,903 in Year 1 and $324,639 in Year 2.
42.93% of net reimbursement after CoachCare's fees: 41.90% in Year 1, 43.75% 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 148 + CCM 78 + APCM 68 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM | $297,760 | $167,178 | $130,583 |
| CCM | $188,896 | $94,001 | $94,896 |
| APCM | $94,885 | $52,057 | $42,828 |
| Implementation, athenahealth integration, outreach | — | $18,657 | −$18,657 |
| 24-month total | $581,542 | $331,892 | $249,650 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the practice and never deducted from its margin. | |||
| Year | Net reimb. | CoachCare fees | Net to practice | Margin |
|---|---|---|---|---|
| Year 1 | $256,903 | $149,271 | $107,632 | 41.90% |
| Year 2 | $324,639 | $182,621 | $142,018 | 43.75% |
| 24 months | $581,542 | $331,892 | $249,650 | 42.93% |
Recurring care-management and monitoring volume over 24 months, filed by the practice's own billing team.
Blood pressure, weight and glucose, a continuous picture of the hypertension and diabetes cohorts between visits.
About $306,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 3,948 care-team hours of monitoring, outreach and documentation carried by the service line, not by clinic staff.
APCM reaches its ceiling of 68 enrollments in month 3, CCM its ceiling of 78 in month 5, and RPM its ceiling of 148 in month 7. From there the census holds at 294 program enrollments, 192 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: 36 new enrollments in month 1, 60 in month 2, 66 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 148 | 650 in scope × 65% eligible (422) × 35% acceptance | Month 7 |
| CCM | 78 | 650 × 40% (260) × 30% | Month 5 |
| APCM | 68 | 650 × 35% (227) × 30% | Month 3 |
| At month 24 | 294 | Program enrollments = 192 patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working the clinic, including the evening and Sunday hours. Without that specialist the same ceilings are reached in months 16, 11 and 6 instead of 7, 5 and 3, and 24-month net reimbursement falls to $483,579. The specialist cannot raise a ceiling. Reaching it months sooner is worth $97,963 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 650 patients here is a careful estimate; a rural health clinic's Medicare visits are billed institutionally, so the panel does not show in the physician fee-schedule data, and the practice's own count by site is discovery item one. At the low end of the credible range, 400 patients, the program is $371,834 of 24-month net reimbursement; at 900 it is $775,648. The second lever is the Highland site, whose Medicare panel is still young, and the Medi-Cal question below.
Medi-Cal is the practice's larger book, and the honest answer on remote care there is precise. California pays physicians and qualified health professionals for remote monitoring and chronic care management under fee-for-service. But a rural health clinic is paid a single per-visit rate, and Medi-Cal's own rural-clinic manual does not treat remote monitoring as a billable clinic service. So the Medicare rail on this page is the one that pays today.
The point of the service line is the between-visit revenue Medicare already pays a rural health clinic for. The Medi-Cal panel is where the clinical need is largest, and it is the reason to have the monitoring infrastructure in place when a plan arrangement opens.
The practice runs on athenahealth, and this plan is priced on CoachCare's athenahealth 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 athenaCollector; and the practice'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 athenahealth chart. One chart, no second system for clinicians.
Claims are created automatically in athenaCollector with the care-management codes on them, and the practice's own billing team files them. No PDFs, no re-keying.
The practice'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 the community hospital three blocks away 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 practice 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.
Crescent City is the far northwest corner of California, 80 miles from the nearest metropolitan hospital, on a Medicare book that is almost entirely fee-for-service. Highland sits in the Inland Empire, a majority-Hispanic community on a Medi-Cal book. A program that works across both has to travel, not assume broadband, and speak the patient's language. Six design decisions follow.
Every cuff, scale and glucometer ships with its own cellular connection and transmits on its own. No smartphone, no home internet, no rural broadband, no app to install. The device works the day it comes out of the box, which matters most in a county where home connectivity is not a given.
A daily reading from home is a visit that did not require an 80-mile drive. For a housebound or transport-limited patient in Del Norte, the monthly touch is the difference between a managed condition and one that is only seen when it lands in the emergency room.
Device instructions and call scripts in both languages, matched to the language on the patient's chart. It matters most at the Highland site, where more than half the community is Hispanic and one in seven residents speaks English less than very well.
The Crescent City clinic is open into the evening and on Sundays, and the on-site enrollment specialist works those hours. Consent, device setup and the first reading happen face to face, on the days working families actually come in.
Lists come from the hypertension and diabetes cohorts first, then by site and payer, so the Medicare rail fills where the fee-for-service panel is and the two clinics are enrolled on their own timelines rather than as one blended number.
Five of the six primary-care clinicians are nurse practitioners or physician assistants. The care-management codes are built for general supervision and do not require a physician visit, so the team as it stands today, and the roles the clinic is recruiting for now, fit the way the codes work.
Crescent City serves Del Norte County, one of California's most rural and most fee-for-service Medicare markets. Highland serves the Inland Empire, dense, majority-Hispanic and majority Medicare Advantage. The same remote-care engine earns its keep in both, for opposite reasons: in Del Norte because the codes pay per claim on an older panel, in Highland because it is the Medicare revenue line a new site needs while its panel grows.
California's rural health transformation funding names telehealth and remote monitoring among its stated priorities for rural clinics; whether it reaches this practice is a question for the working session, not a number in this forecast.
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 rural health clinic 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 $283,781 of the $581,542 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $4,707 of the $33,053 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 practice 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 practice 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 rural health clinic 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 practice's physician, nurse practitioners and physician assistants govern protocols and every clinical decision. Launch needs no new clinic headcount and no capital; the athenahealth integration runs in parallel with onboarding, and the first enrollments follow the first orders.
athenahealth integration scoped and started; named program lead at the practice; P&L and scorecard; claim configuration with the billing team; protocol sign-off for the hypertension and diabetes pathways; the evening and Sunday enrollment hours loaded into the outreach rules; the discharge trigger wired to the three-touch cadence.
APCM across the primary-care panel, CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts, Crescent City first; CoachCare's on-site enrollment specialist working the clinic, evenings and 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 owner, with the blood-pressure and diabetes control measures a lifestyle-medicine practice already tracks.
Bring the Highland site fully online as its Medicare panel grows, take up the Medi-Cal question with the plans, bring transitional care to every discharge, and add behavioral health integration as the next arm alongside the mental-health services already in the building.
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.