Bond already carries accountable-care risk, a Medicare Shared Savings Program ACO on the Advance-Investment glide path since January 2025, and it is a national quality leader on heart health. Since last year, Medicare pays a health center for the month of care between visits as its own codes, at national amounts, on top of every visit. That is the line that moves the blood-pressure and total-cost numbers the ACO is graded on, and it does not exist here yet. The panel is small and fills in five 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. 118 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 181 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $155,934 of the $368,221 is the health center's after CoachCare's fees.
A health center that has served Tallahassee and the surrounding Big Bend counties for more than thirty years, grew into behavioral-health integration, a specialty and community wellness center, an HIV program and a mobile medical unit, and earned a national quality-leader recognition for heart health. In January 2025 it took on accountable-care risk for its Original-Medicare panel. The work between visits is what that risk is graded on, and there is no revenue line under it yet.
Bond reported 9,079 patients across eight Big Bend counties in 2024, about 1,014 of them with Medicare as their primary coverage. This forecast is built on the Original-Medicare share of that panel, the patients a health center bills these codes for cleanly and the patients the accountable-care work follows.
Bond joined a Medicare Shared Savings Program ACO on the upside-only BASIC track, with an Advance Investment Payment, in January 2025. It is now responsible for the quality and total-cost-of-care numbers on its Original-Medicare panel, and those are exactly the numbers a documented monthly care line moves.
Bond earned a 2025 National Quality Leader Heart Health recognition. Controlled blood pressure sits at 53.5% and statin therapy at 87.2%. Controlled blood pressure is the one measure continuous readings and a documented monthly touch move fastest, and it is the measure Bond is recognized on.
Bond runs on athenaOne, holds Patient-Centered Medical Home recognition, and already reaches patients outside the exam room through a mobile unit and its own transportation service. The infrastructure a remote-care line needs is largely here; the line itself is not.
One structural fact completes the picture: no remote patient monitoring, chronic care management or advanced primary care management program runs at Bond today, and no care-manager or monitoring role is on its careers page. A health center bills these services institutionally, so they would not surface in the physician fee-schedule file regardless, but the site and the roster are clear: the between-visit line does not exist yet. Patients with hypertension and diabetes are seen a few times a year. Between those visits there is no revenue line, and nothing moving the measures the ACO is graded on.
Two changes made the between-visit month billable for a health center, and a third, Bond's move into accountable care, made it matter twice: once as revenue, once as the work that moves total cost of care.
Care management used to bill as one bundled health-center code, G0511. Since 2025, a health center bills chronic care management, remote monitoring and advanced primary care management as individual codes at the national non-facility amounts, in addition to the PPS encounter for the visit. Each service is paid on its own, every month it is delivered. The figures on this page are priced at the national amounts a health center 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 one of the Tallahassee acute-care hospitals can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $36,526 of reimbursement over 24 months before denials and bad debt, about 9.9% of net reimbursement.
Advanced primary care management pays a flat monthly amount by tier: $16.37, $53.78, and $117.24 for a dual-eligible patient who is a Qualified Medicare Beneficiary. On this panel the tier mix blends to $52.90 per patient-month, a monthly payment for the longitudinal primary-care work the accountable-care model already expects Bond to do. The enrollment and engagement labor that earns it is CoachCare's.
A named service line with its own P&L and scorecard, following the Original-Medicare patients the health center 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 as the monthly payment for the longitudinal panel the accountable-care model already holds Bond responsible for.
| 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 Tallahassee acute-care hospitals; 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 health center bills the care-management codes on in addition to the PPS encounter, and the basis every figure on this page is priced on.
A 24-month forecast for the RPM + CCM + APCM stack: the health center's own 400 Original-Medicare patients, all of them in scope from month one, nine physicians and nurse practitioners plus CoachCare's enrollment outreach, the national amounts a health center is paid, and the athenahealth integration. Medicare Advantage lives, transitional care, behavioral health integration and Florida Medicaid are not in these numbers; each is upside scoped below.
After denials and coinsurance bad debt; $172,471 in Year 1 and $195,750 in Year 2.
42.35% of net reimbursement after CoachCare's fees: 41.02% in Year 1, 43.52% 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 5.
RPM 91 + CCM 48 + APCM 42 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $194,927 | $109,508 | $85,418 |
| CCM | $121,139 | $60,283 | $60,857 |
| APCM | $52,155 | $28,025 | $24,130 |
| Implementation, athenahealth integration, outreach | — | $14,471 | −$14,471 |
| 24-month total | $368,221 | $212,287 | $155,934 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the health center and never deducted from its margin. | |||
| Year | Net reimb. | CoachCare fees | Net to health center | Margin |
|---|---|---|---|---|
| Year 1 | $172,471 | $101,729 | $70,741 | 41.02% |
| Year 2 | $195,750 | $110,557 | $85,193 | 43.52% |
| 24 months | $368,221 | $212,287 | $155,934 | 42.35% |
Recurring care-management and monitoring volume over 24 months, filed by the health center's own billing team.
Blood pressure, weight and glucose, a continuous picture of the hypertension and diabetes cohorts between visits.
About $200,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 2,562 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 42 enrollments in month 2, CCM its ceiling of 48 in month 3, and RPM its ceiling of 91 in month 5. From there the census holds at 181 program enrollments, 118 patients; month 12 and month 24 are the same number. The binding constraint on this forecast is the size of the Original-Medicare panel in scope, not enrollment capacity and not clinician count. The first 90 days, modeled: 41 new enrollments in month 1, 58 in month 2, 48 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 91 | 400 in scope × 65% eligible (260) × 35% acceptance | Month 5 |
| CCM | 48 | 400 × 40% (160) × 30% | Month 3 |
| APCM | 42 | 400 × 35% (140) × 30% | Month 2 |
| At month 24 | 181 | Program enrollments = 118 patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working across Bond's Tallahassee sites. Without that specialist the same ceilings are reached in months 8, 6 and 4 instead of 5, 3 and 2, and 24-month net reimbursement falls to $344,744. The specialist cannot raise a ceiling. Reaching it months sooner is worth $23,477 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 panel it runs on, and this base is the Original-Medicare share of Bond's Medicare patients. Leon County Medicare is majority Medicare Advantage; as those plans contract to pay these code families at parity, the in-scope panel grows. On a 650-patient panel the same program is $578,400 of 24-month net reimbursement; on the full Medicare panel it is $861,003. The second lever is the Florida Medicaid remote-monitoring rail below, and the third is the total cost of care the accountable-care model already rewards.
Two in three of Bond's patients are uninsured or on Medicaid, and most of its hypertensive and diabetic patients are among them. Florida Medicaid has covered remote physiologic monitoring since July 2022, using the same device and management codes as the Medicare program. That is a second, larger population the program's devices and care team already know how to serve.
Florida Medicaid coverage policy; remote patient monitoring covered for dates of service on or after July 21, 2022. Florida Medicaid does not separately pay chronic care management, advanced primary care management, transitional care management or behavioral health integration; those are Medicare rails here. The per-code amounts, and whether a health center bills these separately from the PPS encounter, are confirmed with the state in the working session.
Bond runs on athenaOne, and this plan is priced on CoachCare's built-in athenahealth integration, so clinicians enroll and monitor patients without learning a new system. It carries the full flow: bidirectional enrollment by service, exchange of health history, integrated discrete vitals, escalation tasks, compliance documentation and integrated care summaries, and automated claim generation. CoachCare is the only care-management partner that creates athenahealth claims automatically, and an enrolled patient begins care in under five days, inside the workflow the team already uses.
A physician, PA or NP flags an eligible patient and places the order inside athenahealth, 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 the athenahealth billing workflow with the care-management codes on them, and the health center's own billing team files them. No PDFs, no re-keying.
The health center'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 one of the Tallahassee acute-care hospitals 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 health center 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.
A remote care program that works across eight rural and small-city counties is not the one built for a dense retirement suburb. Distance is the adherence barrier here, a third of the panel is uninsured, and Bond already carries patients the rest of the system misses. Five design decisions follow from that.
Every cuff, scale and glucometer ships with its own cellular connection and transmits on its own. No smartphone, no home internet, no app to install, no account to set up. The device works the day it comes out of the box, which matters most where broadband does not reach.
Bond's patients are spread from Tallahassee across seven surrounding counties, and a visit can mean a long drive. A documented monthly contact, and a device already in the home, reaches patients that an office calendar and a windshield do not, alongside the mobile unit and transportation Bond already runs.
Device instructions and call scripts in English and Spanish, written plainly and matched to the language on the chart. The program is designed for a panel where a third of patients are uninsured and many are new to remote care.
Lists come from the hypertension and diabetes registries first, then payer, so the Original-Medicare rail, the Medicare Advantage panel and the Florida Medicaid rail each get the patients who belong on them, and the accountable-care panel is worked first.
Most of the nine adult-primary-care clinicians are nurse practitioners. The care-management codes are built for general supervision, so the team as it stands today fits the way the codes work, without new hires.
Bond serves Tallahassee and seven surrounding Big Bend counties from three clinical sites, a specialty and wellness center and a mobile unit. Its Medicare population is majority Medicare Advantage, and the Original-Medicare share it is accountable for is exactly where the between-visit line bills cleanly.
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 health center 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 $173,294 of the $368,221 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $3,020 of the $21,578 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 health center 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 health center 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 health center 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 health center's physicians, physician assistants and nurse practitioners govern protocols and every clinical decision. Launch needs no new health-center 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 health center; P&L and scorecard; claim configuration with the billing team; protocol sign-off for the hypertension and diabetes pathways; the eight-county outreach and transportation workflow loaded into the enrollment rules; the discharge trigger wired to the three-touch cadence.
APCM across the Original-Medicare panel, CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts; CoachCare's on-site enrollment specialist working across Bond's Tallahassee sites; the post-discharge cadence live from day one.
APCM fills in month 2, CCM in month 3, RPM in month 5; monthly scorecard to the executive team, with the blood-pressure control measure Bond is recognized on at the top of it.
Re-run eligibility against the payer reconciliation, contract the Medicare Advantage panel toward parity, size and launch the Florida Medicaid remote-monitoring line from the registries, bring transitional care to every discharge, and add behavioral health integration as the next arm.
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.