Have you ever considered going to the doctor not only when you are sick but also to stay well overall and avoid complications? This is the idea behind chronic care management (CCM). Millions of people live with long-term health conditions that do not go away, and without proper care, these conditions can take a toll on everyday life. That is where CCM comes in.

Chronic care management is a Medicare-supported program designed to help people with two or more chronic conditions. These are health problems that last a year or more and can affect daily life. 

With CCM, your healthcare provider creates a custom care plan and stays in touch with you between visits. This may include phone calls and medication management. The goal of CCM is simple, to improve your quality of life and prevent avoidable hospital visits. 

If you or a loved one is dealing with ongoing health issues like diabetes, heart disease, or arthritis, you may qualify for a special Medicare service that helps manage these conditions better. But which conditions qualify for CCM?

Let us explore that in simple terms.

What Does “Chronic Condition” Mean Under CCM?

A chronic condition, according to Medicare, is a health issue that:

• Lasts at least 12 months, or
• Is expected to last for the rest of your life, and
• This puts you at risk of serious health decline or even death without proper care

This means short-term illnesses like the common cold or a stomach bug do not count. Chronic conditions stick around and need ongoing care.

General CMS Criteria for CCM Eligibility

The Centers for Medicare & Medicaid Services (CMS) has set some rules for who qualifies for CCM. Once all of these boxes are checked, a provider can enroll the patient in CCM.

To be eligible, a patient must:

Have two or more chronic conditions

The first requirement is straightforward: you need to be living with at least two chronic (long-term) conditions.

A chronic condition is any health problem that:

• Does not go away after a short time
• Requires regular management, such as medications, monitoring, or lifestyle changes
• It can get worse if not treated properly
• Affects your daily life or overall health

Examples include high blood pressure, diabetes, asthma, arthritis, and heart disease.

The conditions must be expected to last at least 12 months (or until death)

CMS requires the conditions to be long-lasting, which means the condition is not temporary or it would likely be part of your life for at least a year. Moreover, it could also mean that the disease is expected to continue until the end of life. 

An example of this is that Alzheimer’s disease slowly worsens over time and has no cure. 

The conditions must pose a significant risk to health or daily functioning.

CMS Focus	What It Means for the Patient
Increased Risk	You are more likely to face complications, hospitalization, or worsening symptoms if not monitored regularly.
Functional Decline	You may experience difficulty doing daily activities like walking and bathing.
Complex Care Needs	Your care plan may involve multiple specialists or treatments over time.

The patient must give verbal or written consent to receive CCM services

Before a provider can begin Chronic Care Management (CCM), the patient must give clear permission, either verbally or in writing. This ensures the patient understands what CCM includes, and any potential costs (like a small monthly copay), and agrees to participate in the service.

List of Common Conditions That Qualify for CCM

Now, we will take a closer look at the most common chronic conditions that qualify under the CCM program. 

1. Cardiovascular Conditions

Cardiovascular conditions affect the heart and blood vessels.   

Hypertension (High Blood Pressure)	Often called the "silent killer," this condition increases the risk of heart attacks, strokes, and kidney problems.
Coronary Artery Disease (CAD)	This is when the arteries that supply blood to the heart become narrowed or blocked. It can cause chest pain and lead to heart attacks.
Congestive Heart Failure (CHF)	A chronic condition in which the heart does not pump blood as effectively as it should. Symptoms include fatigue, shortness of breath, and swelling.
Atrial Fibrillation (AFib)	An irregular heart rhythm can lead to blood clots, strokes, and heart failure. AFib often requires medication and ongoing monitoring.

2. Respiratory Conditions

These involve the lungs and airways, and they can make daily activities like walking or climbing stairs very difficult.  

Chronic Obstructive Pulmonary Disease (COPD)	This is a group of diseases, mainly emphysema and chronic bronchitis, that block airflow and make it hard to breathe. It gets worse over time.
Asthma	A condition where the airways swell and narrow, causing difficulty breathing, coughing, and wheezing. Severe or poorly controlled asthma may qualify for CCM.
Pulmonary Fibrosis	Scarring in the lungs makes it hard to breathe and get enough oxygen into the blood.

3. Endocrine and Metabolic Conditions

These affect how your body uses hormones and energy.  

Diabetes (Type 1 and Type 2)	Affects how your body processes sugar. Can lead to nerve damage, vision problems, kidney failure, and more if not well-managed.
Obesity	When a person has too much body fat, it increases the risk for many other chronic diseases like heart disease and diabetes.
Hyperlipidemia	This refers to high levels of fats (such as cholesterol and triglycerides) in the blood.
Hypothyroidism	When the thyroid gland does not make enough hormones, it can lead to fatigue, weight gain, and depression.

4. Neurological and Mental Health Conditions

Affected areas may include the brain, nerves, and mental wellness, and many of them last a lifetime.  

Alzheimer’s Disease and Other Dementias	These cause progressive memory loss and changes in behavior, often requiring caregiver support and a comprehensive care plan.
Depression	Long-term depression is more than feeling sad, it can affect sleep, appetite, and overall functioning.
Anxiety Disorders	Ongoing anxiety can interfere with daily life and may require medical treatment, counseling, or both.
Parkinson’s Disease	A progressive disorder of the nervous system that affects movement. Symptoms include tremors, stiffness, and balance problems.
Multiple Sclerosis (MS)	A chronic disease that affects the brain and spinal cord, causing a wide range of symptoms from numbness to paralysis.

5. Musculoskeletal Conditions

These affect the bones, joints, and muscles, and are a common cause of long-term pain and mobility issues.  

Arthritis (including Osteoarthritis and Rheumatoid Arthritis)	Causes joint pain, stiffness, and inflammation. It can limit movement and affect the quality of life.
Osteoporosis	A condition where bones become weak and fragile. Increases the risk of fractures, especially in older adults.
Chronic Back Pain	Long-term back pain due to injury, degeneration, or other spinal issues often needs continuous therapy and treatment.

6.  Renal Conditions

Chronic Kidney Disease (CKD)

Progressive loss of kidney function can lead to kidney failure if not treated properly. Requires regular lab tests, medications, and sometimes dialysis.

Other Qualifying Conditions

These conditions may not always make the “common” list, but they are still eligible under CCM if they meet Medicare’s criteria.

• Chronic Fatigue Syndrome

A long-term condition that causes extreme tiredness, even after rest, making everyday tasks difficult to manage.

• Chronic Pain

Persistent pain that lasts for months or longer and affects daily life, often needing medications, therapy, or multiple doctor visits.

• Chronic Migraine

Severe headaches occur frequently (15 or more days a month), often disrupting work, sleep, and quality of life.

• Fibromyalgia

A condition that causes widespread pain, fatigue, and sleep problems, often requiring coordinated care and long-term symptom management.

• HIV/AIDS

A chronic viral infection that weakens the immune system and requires lifelong treatment and careful monitoring.

• Lupus

An autoimmune disease where the immune system attacks the body’s own tissues, which affects skin, joints, kidneys, and other organs.

• Multiple Sclerosis (MS)

A neurological condition that affects the brain and spinal cord.

• Parkinson’s Disease

A progressive disorder affecting movement and coordination, often needing medication adjustments and physical therapy over time.

• Post-Traumatic Stress Disorder (PTSD)

A mental health condition triggered by trauma, which may involve anxiety, flashbacks, and depression, requires consistent psychological support.

• Schizophrenia

A severe mental disorder that impacts thinking, emotions, and behavior, requiring regular psychiatric care and medication management.

Patients with Multiple Chronic Conditions

The key requirement for CCM is having two or more chronic conditions. This is important because many people, especially older adults, have more than one ongoing health problem.

For example, a patient with:

• Diabetes
• Hypertension

…would qualify.

Another patient with:

• COPD
• Osteoporosis

…would also qualify.

It does not matter which two conditions a person has, as long as they meet the criteria of being long-term and potentially serious. Having multiple chronic conditions increases the chances of health complications, and CCM helps to reduce those risks by keeping everything coordinated.

How Providers Determine Eligibility

Healthcare providers use clinical judgment and medical records to decide if a patient qualifies for CCM. They look at:

• The diagnosis history (from lab tests, and hospital records)
• Whether the patient has had the condition for at least 12 months or is expected to
• If the condition requires ongoing treatment, such as medications, lifestyle changes, or specialist visits
• Whether managing the condition involves multiple providers or care coordination

What happens next?

Once this assessment is made, providers will discuss CCM services with the patient. If the patient agrees, the provider documents the consent and begins the care plan.

Why Accurate Diagnosis Coding Matters

You might not think much about medical coding, but it plays a huge role in CCM. When doctors enter your diagnoses into their system, they use ICD-10 codes, a universal language used for billing and documentation.

If these codes are incomplete or incorrect, it could mean:

• You are not flagged as eligible for CCM
• Your insurance (like Medicare) may not cover the service
• Your care plan might be missing key information

That is why accurate coding matters. It ensures that your health conditions are properly documented and that you get the support you need under the CCM program.

Final Thoughts on CCM-Eligible Conditions

While managing severe health issues, chronic care management (CCM) helps people lead better, healthier lives. But first, you need to know who is eligible for this. See a doctor about CCM if you or someone you know is having trouble managing several chronic medical issues.

If your clinic or healthcare organization needs assistance establishing or enhancing a CCM program, Tellihealth can help.