Medicare Between Visits

By Amanda Krupa

For two decades, Chicago-area health journalist Amanda Krupa has covered caregiving, aging, and access to care — where public health meets everyday life. Read more

How Chicagoland health systems support patients between visits

Fact checked by Shannon Sparks

The diagnosis came on top of everything else. An older woman on the West Side, already living with dementia, was diagnosed with cancer. Her daughter worried about symptoms, appointments, and what to do in the long stretches between doctor visits. That’s when Rush University Medical Center’s home-based primary care team stepped in. Nurses handled symptom questions, a social worker coordinated services, and the family got a direct line for the next step.

That’s the aim of care management programs: real help between visits.

Two Medicare Part B benefits — Chronic Care Management (CCM) and Advanced Primary Care Management (APCM) — cover care coordination, medication support, and 24/7 clinical access. Yet many eligible patients don’t know these benefits exist.

Care coordination 101

“Medicare created CCM in 2015 to pay clinics for the crucial between-visit work that helps people with chronic conditions stay stable,” says Shane Grivich, co-founder of ChartSpan, a full-service CCM provider that partners with hospitals and clinics nationwide.

A federal evaluation of the program’s first two years found that total Medicare spending grew more slowly — by about $28 to $74 less per patient per month — driven by fewer hospitalizations and emergency room visits.

“For caregivers, the big value is the day-to-day offload — medication refills, appointment scheduling, education, social needs, and a 24/7 nurse line,” Grivich says. “We can help find food pantries, arrange transportation, and get things like walkers or shower aids when needed.”

In 2025, Medicare added APCM, a monthly bundle that reduces paperwork, allowing more practices to deliver this support. It’s part of Medicare’s larger goal to move most beneficiaries into prevention-focused, coordinated care programs by 2030.

Among Chicago health systems, care management takes different forms. Some bill Medicare; others fund similar services internally. All aim to support patients and families during the challenging stretches between medical appointments, when symptoms flare and questions arise.

Managing chronic care

Silver Cross in New Lenox, Illinois, has expanded its CCM program from 2,400 enrolled patients in 2024 to 3,800 today, supported by a 13-member care team. Patients learn about the program during office visits, from text-to-enroll brochures, and through targeted outreach, says Michelle Fisher, director of medical group development.

The team screens for social needs, partners with the Northern Illinois Food Bank, and maintains a local resource list for transportation, housing, and utility assistance. Fisher recalls a patient who faced eviction while she was very sick with Covid-19. Even though she already had a lot to deal with, her primary concern was that her teenage son would have to change schools.

“Our care team reached out to Catholic Charities and helped her find a new home. That was a true win,” Fisher says.

A 2024 analysis of Silver Cross’ enrolled CCM patients showed 89% engagement, with 83% completing depression screenings, 71% receiving annual wellness visits, 51% maintaining and 42% reducing BMI, and 46% reducing blood pressure.

Northwestern Medicine currently funds system-wide care coordination internally. Nurses and social workers provide comprehensive monthly support to adults with chronic conditions and barriers to care, regardless of insurance, citing reduced costs from fewer unnecessary hospital admissions and shorter hospital stays.

“We do a lot of work with patients living with diabetes, which can be really complicated to manage,” says Kelly Pigott, who directs ambulatory care coordination and the post-acute network. “It’s not just understanding more about your disease, but it’s also knowing how to take your prescribed medications, how to measure your blood pressure, when to get your labs taken, what kind of lifestyle changes need to be implemented in a way that fits your culture and budget.”

Rush University Medical Center’s Rush@Home is a home-based primary care program that delivers services to patients’ homes on Chicago’s West Side and in nearby suburbs. The team began billing CCM in November 2023 and has enrolled more than 200 patients so far, says Elizabeth Davis, MD, the program’s medical director.

Rush@Home social workers, nurses, and medical assistants help families navigate state programs to adjust paid caregiver hours and troubleshoot issues related to food, transportation, medical equipment, refills, and symptom questions between visits.

“For many, high-quality in-home primary care visits plus phone follow-up help prevent an ED trip or hospitalization,” Davis says. Rush is also evaluating APCM for potential scale across primary care.

Costs and access

Under original Medicare, CCM and APCM programs usually have 20% coinsurance after the Part B deductible. “Averages can be about $12 per month, depending on supplemental coverage, Grivich says. “Care management can work like a gym membership — the more you use it, the more value you get.”

If Medicaid fully covers you — either because you have both Medicare and Medicaid or because you are in the Qualified Medicare Beneficiary program — providers will not bill you for CCM or APCM. Many dual-eligible patients pay $0 for these services.

For free help comparing coverage, contact the Illinois Senior Health Insurance Program at (800) 252-8966 (711 TRS) or aging.ship@illinois.gov. Counselors can explain Medigap coinsurance for CCM, how Advantage plans handle it, and how to switch plans.