CCM enrollment lags well behind clinical eligibility at most practices. A patient can fit the broad clinical profile for Chronic Care Management and still never be enrolled. The gap between potential eligibility and completed CCM enrollment is not unusual. It is the product of multiple decisions and handoffs between a practice’s patient panel and the delivery of care between visits.
A 2026 study examined 2015 to 2020 Medicare claims for 885,132 beneficiaries in Illinois, Iowa, Minnesota, and Wisconsin who had diabetes, at least one co-occurring chronic condition, and an evaluation and management visit. Only 9,075 beneficiaries, or 1.0%, had a CCM claim. Patients in non-urban areas were less likely to be enrolled. [1]
That figure is evidence of limited enrollment, not proof that the other 99% should have been enrolled. Claims data cannot establish individual medical necessity or patient preference. The same study also found no statistically significant difference in mortality after CCM initiation, so it should not be used to make an outcomes claim. Its relevance here is narrower: even within a population that resembled the intended CCM population, enrollment was rare.
The pattern is not confined to one region or one year. A national study of Medicare fee-for-service beneficiaries with two or more chronic conditions found that CCM enrollment increased from 1.1% in 2015 to 3.4% in 2019. [2] Enrollment expanded, but it remained shallow relative to the size of the potentially eligible population.
What turns potential eligibility into CCM enrollment?
CMS describes CCM as the management of two or more chronic conditions expected to last at least 12 months, or until death, when those conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. A Chronic Care Management program includes much more than identifying diagnoses. Required service elements include a comprehensive electronic care plan, care coordination, continuity, patient access to the care team, and support between visits. [3]
Eligibility does not create enrollment on its own. Enrollment depends on an operating chain that can identify appropriate patients, apply clinical judgment, explain the service, complete onboarding, confirm delivery capacity, and support each patient month after month.
| Identify | Select | Explain | Onboard | Deliver | Continue |
|---|---|---|---|---|---|
| panel | clinically | to patient | with owner | with capacity | each month |
Every transition represents an operational handoff where CCM enrollment can stall.
1. Panel identification
The first task is to find patients who may merit clinical review. An EHR or population-health query can screen for two or more chronic conditions and may incorporate signals such as medication burden, repeat admissions, emergency department use, or gaps in follow-up. CMS explicitly notes that practices may consider factors such as the number of illnesses, medications, or repeat admissions and emergency visits when identifying patients who may require CCM. [3]
This query should create a candidate list, not an enrollment list. A diagnosis count alone does not show whether the duration, risk, care needs, or patient circumstances support CCM. Point-of-care workflows that surface remote-care eligibility during the visit can shorten the lag between identification and a clinical conversation, but the clinician still determines appropriateness.
2. Clinical selection
A practitioner must move the patient from possible fit to an individualized clinical decision. That means assessing whether the chronic conditions meet CMS duration and risk criteria, whether CCM can address an identifiable care need, and whether another service or care pathway is more appropriate.
The 2026 CCM eligibility and consent requirements provide a practical starting point. For new patients, or patients not seen within the previous year, CMS also requires an initiating visit before CCM begins. [3] The distinction between a screening flag and a completed clinical determination is part of a defensible CCM pathway. It also protects patients from being approached on the basis of a list that has not been clinically validated.
3. The patient conversation
A clinically appropriate patient still needs a clear reason to participate. The conversation should explain what CCM is, what help the patient can expect between visits, who will contact them, how information returns to the practice, and how possible cost sharing applies. CMS requires practices to explain the availability of CCM, possible cost-sharing responsibilities, that only one practitioner can provide and bill the service in a calendar month, and the patient’s right to stop the service. [3]
The purpose is not to secure a quick yes. It is to support an informed decision. Earlier qualitative research found that provider concerns about consent and cost-sharing discussions could make practices hesitant to recruit patients, while patients sometimes misunderstood program eligibility and benefits. [4] A familiar clinical voice, plain language, and space for questions can reduce that friction without minimizing patient choice.
4. Enrollment and onboarding
Consent is necessary, but it is not the end of enrollment. The practice also needs to document whether the patient accepted or declined, confirm contact preferences and availability, identify caregiver involvement where appropriate, and collect the information needed to begin a patient-centered care plan.
Every accepted patient should leave the enrollment step with a named owner, a defined next action, and a target date for first contact. If consent is recorded in a note but no task, queue, or accountable team member is created, the patient is enrolled administratively but has not yet gained practical access.
5. Confirmed delivery capacity
Enrollment should not outrun the practice’s ability to deliver. Capacity means more than having staff names on an organization chart. It includes caseload design, scheduled outreach time, care-plan workflows, documentation tools, escalation paths, coverage during absences, and reliable communication back to the billing practitioner.
Some practices build this internally. Others extend their clinical monitoring capacity with clinical staff working under the practice’s direction and applicable supervision requirements. The operating model can vary. The essential question is the same: can the program consistently deliver the services it is offering?
A 2026 mixed-methods study of six rural Wyoming primary care practices found that communication, leadership engagement, and regular evaluation strongly distinguished higher from lower CCM implementation. [5] The study is small and rural-specific, so its findings should not be treated as a universal formula. They do reinforce a practical point: capacity depends on management and feedback systems as well as headcount.
6. Continuing monthly support
CCM enrollment is sustained through repeated service, not completed at sign-up. CMS describes continuity as 24/7 access for urgent needs, a designated care-team member who remains in regular contact, and ways for patients and caregivers to communicate with the practice. It also calls for a comprehensive care plan, medication review, preventive-service support, and coordination across care transitions. [3]
The practical goal is continuous, collaborative care between visits. Patients should know what happens next, how to reach the team, and how the monthly work connects to their goals. Practices need closed-loop workflows so that new information, unmet needs, and escalations reach the appropriate clinician instead of ending in a disconnected note.
Where does CCM enrollment stall?
A practice can diagnose its enrollment gap by looking at each handoff separately. The most useful measures are operational signals, not a single headline enrollment number.
| Handoff | Common failure signal | Useful operating control |
|---|---|---|
| Identify | Few patients reach clinical review | Defined panel query, review cadence, and accountable owner |
| Select | Candidate lists move forward without documented clinical judgment | Explicit qualification criteria and practitioner decision |
| Explain | Patients decline because the service or cost is unclear | Plain-language script, clinical context, and documented questions |
| Onboard | Consent is documented but first contact is delayed | Named owner, next task, contact preferences, and target date |
| Deliver | Enrollment exceeds available monthly capacity | Caseload limits, scheduled outreach, coverage, and escalation pathways |
| Continue | Monthly work becomes inconsistent or disconnected | Care-plan review, closed-loop communication, and regular program evaluation |
Four design rules for expanding CCM enrollment responsibly
- Count completed handoffs, not just names on a list. A candidate, a clinically selected patient, a consented patient, and an enrolled patient are different operational states.
- Base enrollment on delivery capacity. The size of the query result does not determine how many patients a program can support safely and consistently.
- Keep the clinical team close to the patient conversation. Questions about fit, cost, goals, and care needs should have an accountable clinical route, even when outreach is delegated.
- Review reasons, not only rates. Declines, unreachable patients, delayed first contacts, and missed handoffs point to different problems and require different responses.
For the eligibility, consent, coding, and documentation context behind this pathway, read The 2026 Chronic Care Management Guide.
A patient list is not a CCM program
CCM underuse is often described as an awareness problem or a staffing problem. Both can matter, but neither explanation is complete. Enrollment can fail because the right patient was never surfaced, because a screening flag was treated as a clinical conclusion, because the service was not explained clearly, because onboarding stopped at consent, or because the practice did not have the capacity to sustain the work.
The solution is not to promise CCM to every patient who appears on an EHR list. It is to build a predictable and explainable path from potential eligibility to individualized clinical selection, informed patient choice, and dependable service.
Build the operating chain before expanding enrollment.
To discuss the operational design of your CCM program, schedule a CCM consultation with Vivo Care.
Frequently asked questions
What makes a patient eligible for Chronic Care Management?
CMS states that CCM patients must have two or more chronic conditions expected to last at least 12 months, or until death, that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. A diagnosis list can identify candidates, but a practitioner must determine whether the criteria and the patient’s care needs support CCM.
Why does CCM enrollment lag behind eligibility?
There is no single cause. Potential patients can be lost during panel identification, clinical review, the patient conversation, consent and onboarding, capacity assignment, or continuing monthly delivery. Cost sharing, patient understanding, practice priorities, staffing, technology, leadership, and workflow design can all affect enrollment.
Does a patient have to consent to CCM?
Yes. CMS requires written or verbal consent before CCM is billed. The practice must explain the service, possible cost sharing, the one-practitioner-per-month rule, and the patient’s right to stop the service, then document whether the patient accepted or declined.
Can clinical staff deliver CCM services?
Yes. CMS permits qualifying CCM services to be furnished by clinical staff under the billing practitioner’s direction and general supervision, subject to applicable state law, licensure, and scope-of-practice requirements.
How can a practice increase CCM enrollment without over-enrolling?
Set a capacity-based enrollment range, define ownership for every handoff, and track where patients stall. Expand only when the care team can absorb new patients without delaying first contact, care-plan work, escalation, or continuing monthly support.
References
- Ouayogodé MH, Zheng Y. Chronic Care Management and Mortality Among Diabetic Patients with Multiple Chronic Conditions. Population Health Management. Published online April 7, 2026. doi:10.1177/19427891261437477
- Jang J, McCarthy EP, Olivieri-Mui B, et al. Use of Chronic Care Management Service Among Medicare Beneficiaries in 2015 to 2019. Journal of the American Geriatrics Society. 2024;72(9):2730 to 2737. doi:10.1111/jgs.19066
- Centers for Medicare & Medicaid Services. Chronic Care Management Services. MLN909188. June 2025. CMS booklet
- Schurrer J, O’Malley AS, Wilson C, McCall N, Jain N. Evaluation of the Diffusion and Impact of the Chronic Care Management Services: Final Report. Mathematica Policy Research for the Centers for Medicare & Medicaid Services. November 2, 2017. CMS final report
- Punke E, Wall LA, McKibbin CL, Carrico CP, Teply AL. Factors Associated With High vs. Low Implementation of Medicare’s Chronic Care Management Programme in Wyoming Primary Care Practices. Primary Health Care Research & Development. 2026;27:e19. doi:10.1017/S1463423625100741