Explore Medicare care coordination programs including Chronic Care Management (CCM), Annual Wellness Visits (AWVs) and the CMS ACCESS Model.
If you are:
- A Medicare beneficiary managing chronic conditions
- A caregiver helping a loved one navigate healthcare
- A primary care provider evaluating care coordination support
- An ACO leader focused on Medicare outcomes
- A payer or health plan exploring scalable chronic care infrastructure
This guide explains how modern Medicare care management works and how Pair Team supports continuous, AI-enabled care coordination across the healthcare ecosystem.
What is Medicare Care Coordination?
Medicare care coordination helps patients manage their health between doctor visits. For patients with chronic conditions like diabetes, heart disease, hypertension, COPD, depression, or chronic kidney disease, healthcare often becomes fragmented:
- Multiple providers
- Medication confusion
- Missed follow-ups
- Emergency room visits
- Transportation barriers
- Social needs affecting health outcomes
Traditional fee-for-service Medicare was built primarily around appointments, procedures, and individual clinical encounters. But chronic disease management happens continuously, not episodically. Modern Medicare care coordination programs were created to help close those gaps through:
- Ongoing patient outreach
- Medication management
- Appointment coordination
- Chronic care management
- Preventive care support
- Community resource navigation
- Behavioral health coordination
- Between-visit engagement
Today, Medicare supports several care coordination programs designed to improve outcomes while reducing avoidable utilization and total cost of care.
Medicare Programs That Support Care Coordination
Chronic Care Management (CCM) is a Medicare program designed for patients managing two or more chronic conditions expected to last at least 12 months. CCM services may include:
- Medication management
- Care coordination between providers
- Follow-up outreach
- Appointment reminders
- Preventive care support
- Patient education
- Care plan management
Conditions commonly supported through CCM include:
- Diabetes
- Hypertension
- Heart disease
- COPD
- Depression
- Chronic kidney disease
CCM has become one of the most important Medicare chronic care programs because it supports continuous engagement between visits.
Annual Wellness Visits (AWVs) are preventive Medicare visits covered under Medicare Part B. AWVs help identify:
- Health risks
- Preventive care opportunities
- Chronic condition management needs
- Behavioral health concerns
- Care coordination opportunities
Annual Wellness Visits are generally covered at no cost to patients under Medicare Part B. AWVs are often the starting point for identifying patients who may benefit from additional chronic care support programs.
Community Health Integration (CHI) addresses social drivers of health that impact healthcare outcomes. CHI programs may support:
- Transportation assistance
- Food insecurity
- Housing instability
- Community resource coordination
- Social support navigation
These services are increasingly important for Medicare populations with complex medical and social needs.
What Is the CMS ACCESS Model?
The CMS ACCESS Model — short for Advancing Chronic Care with Effective, Scalable Solutions — is a Medicare Innovation Center model designed to modernize chronic care delivery. ACCESS represents a major shift in Medicare care management because it supports:
- Continuous patient engagement
- Technology-enabled care coordination
- AI-supported chronic disease management
- Outcome-focused reimbursement
- Scalable between-visit care
Unlike traditional fee-for-service Medicare models that reimburse individual services, ACCESS is designed around improving patient outcomes over time. ACCESS also allows Medicare providers like Pair Team to waive beneficiary copay requirements. The ACCESS Model focuses on conditions including:
- Diabetes
- Hypertension
- Heart disease
- Behavioral health conditions
- COPD
- Chronic kidney disease
The model also encourages:
- FHIR-enabled interoperability
- Virtual care delivery
- Remote patient engagement
- Continuous monitoring
- Coordinated care across providers
Why Medicare is Moving Toward Continuous Care
Healthcare costs are increasingly driven by:
- Unmanaged chronic disease
- Emergency department utilization
- Readmissions
- Medication non-adherence
- Behavioral health gaps
- Social barriers to care
Traditional healthcare systems struggle to maintain continuous patient engagement between appointments. That creates operational challenges for:
- Primary care providers
- ACOs
- Health systems
- Medicare Advantage organizations
- Managed care organizations
- MSSP participants
- ACO REACH participants
Modern Medicare care coordination models help address these gaps through more proactive outreach and ongoing support.
How Pair Team Supports Medicare Care Coordination
Pair Team is an AI-enabled medical group supporting Medicare and Medicaid populations through:
- Continuous patient engagement
- Chronic care management
- AI-enabled outreach
- Clinical coordination
- Community-based support
- Whole-person care
Our model combines:
- Human clinical care teams
- AI-powered coordination
- Social care navigation
- Technology-enabled workflows
- 24/7 patient engagement
At the center of the experience is Flora, Pair Team’s AI health advocate and care coordinator. Flora helps patients:
- Coordinate appointments
- Refill prescriptions
- Navigate Medicare support services
- Connect to transportation or food resources
- Stay engaged between visits
- Escalate concerns to clinical teams when needed
Patients can reach Flora 24 hours a day, 7 days a week by phone or text — no app required.
Medicare Care Coordination for Patients
Who may qualify?
Patients may qualify for Medicare care coordination programs if they have one or more of the following:
- Have Original Medicare (Part A and Part B)
- Have chronic conditions
- Need support managing care between appointments
- Have ongoing medication or specialist coordination needs
Qualifying conditions may include:
- Diabetes
- Hypertension
- Heart disease
- COPD
- Depression or anxiety
- Chronic kidney disease
Do patients need to change doctors?
No. Patients keep their existing doctors and providers. Pair Team works alongside existing care teams to improve coordination and continuity of care.
How much do these programs cost to the patient?
Coverage depends on:
- Medicare eligibility
- Secondary insurance
- Medicaid status
- Program enrollment
- Preventive care eligibility
Many patients may pay little to no out-of-pocket depending on their Medicare coverage and eligibility. Some services — including Annual Wellness Visits — are preventive Medicare benefits covered under Medicare Part B. Before enrollment, Pair Team reviews coverage and potential costs with patients directly.
Medicare Care Coordination for Providers
How Pair Team supports primary care providers
Pair Team is designed to extend existing care management infrastructure rather than replace it. We support providers through:
- Between-visit patient engagement
- Medication follow-up
- Care gap closure
- Social needs coordination
- Appointment coordination
- Behavioral health support
- Escalation workflows
Providers retain clinical oversight while Pair Team handles operational coordination at scale.
Does Pair Team integrate into existing workflows?
Yes. Pair Team is designed to minimize workflow disruption by coordinating within existing provider operations and communication structures.
Medicare Care Coordination for ACOs
For ACOs and health systems, Medicare care coordination programs help improve:
- Chronic disease control
- Shared savings performance
- Utilization management
- Medication adherence
- Patient engagement
- Quality scores
The ACCESS Model in particular creates new infrastructure for:
- Continuous chronic disease management
- Technology-enabled patient engagement
- AI-supported outreach
- Lower-cost care delivery models
Pair Team supports ACOs through scalable patient engagement and care coordination infrastructure aligned with modern Medicare reimbursement models.
Medicare Care Coordination for Payers & Health Plans
Health plans and managed care organizations increasingly require:
- Scalable patient engagement
- Better chronic condition outcomes
- Reduced ED utilization
- Better medication adherence
- Improved member experience
- Lower total cost of care
Pair Team provides:
- Continuous patient engagement
- Reporting and outcomes tracking
- HIPAA-compliant coordination infrastructure
- AI-enabled care workflows
- Social care integration
- Clinical escalation pathways
Pair Team is fully HIPAA compliant and supports secure data sharing and interoperability workflows.
