Medicaid can cover chronic care management services, but coverage depends heavily on which state you live in and how you’re enrolled. Unlike Medicare, which has a standardized national billing code for chronic care management (CCM), Medicaid programs are administered state by state, and each state structures its care coordination benefits differently. If you have both Medicare and Medicaid, the answer is more straightforward: Medicare typically serves as the primary payer for CCM, and Medicaid may cover remaining costs.
How CCM Works Under Medicare vs. Medicaid
Chronic care management is a defined Medicare benefit with specific billing codes. It covers non-face-to-face services (phone calls, care coordination, medication management) for patients with two or more chronic conditions expected to last at least 12 months. Physicians, nurse practitioners, physician assistants, certified nurse midwives, and clinical nurse specialists can bill for these services, and clinical staff like nurses, pharmacists, and medical assistants can deliver care under the direction of the billing provider.
Medicaid doesn’t mirror this structure exactly. There’s no single, federally mandated Medicaid CCM benefit the way there is under Medicare Part B. Instead, states build chronic care coordination into their Medicaid programs through different mechanisms: managed care plans, primary care case management programs, health home models, or targeted case management services. The result is that the type and extent of care management you can access varies significantly depending on where you live.
State-by-State Differences in Coverage
Because each state designs its own Medicaid program within federal guidelines, chronic care management looks different across the country. Some states run statewide programs, while others limit services to certain regions or populations. A few examples illustrate the range:
- Maine and North Dakota operate statewide primary care case management programs that include care coordination for chronic conditions.
- Alabama runs a similar program, but only in 21 of its 67 counties, meaning beneficiaries in other parts of the state may not have access to the same services.
- Vermont takes a broader approach through its Global Commitment to Health program, which includes health homes providing coordinated, whole-person care for Medicaid beneficiaries, including those receiving medication-assisted therapy for opioid dependence.
- Florida negotiates expanded benefits above the standard Medicaid service package through its managed care plans, including targeted case management. The exact expanded benefits vary by plan.
- Utah focuses its case management services more narrowly on behavioral health through county-level partnerships.
If you’re enrolled in a Medicaid managed care plan, your plan may include care management services as part of its benefit package even if the state doesn’t offer a standalone CCM program. Many managed care organizations build care coordination into their contracts because it reduces emergency visits and hospitalizations for members with complex needs. Contact your plan directly to ask what chronic care coordination services are included.
If You Have Both Medicare and Medicaid
About 12 million Americans are “dual eligibles,” enrolled in both Medicare and Medicaid simultaneously. If you’re one of them, Medicare is the primary payer for outpatient services like CCM, and Medicaid typically picks up remaining costs such as copayments. This means the standard Medicare CCM benefit applies to you, covering care coordination for two or more chronic conditions lasting at least 12 months.
Dual eligibles often have the most to gain from chronic care management. People in this group frequently have complex needs spanning chronic disease management, behavioral health care, and long-term care. Some states are moving toward integrated plans (sometimes called Dual Eligible Special Needs Plans, or D-SNPs) that combine Medicare and Medicaid coverage under a single plan. These integrated plans can simplify access to care coordination because one plan manages everything rather than splitting services between two programs.
If you’re enrolled in an integrated plan, your care management benefits may actually be more comprehensive than what either program offers alone, since the plan has a financial incentive to coordinate all your care in one place.
What You’ll Pay Out of Pocket
Medicaid cost sharing is minimal by design. For most beneficiaries, copayments are capped at nominal amounts, typically no more than $4 per service for those in managed care. Several groups are exempt from copayments entirely, including children, people who are terminally ill, and individuals living in institutions.
States can set higher cost-sharing amounts for beneficiaries with incomes above 100% of the federal poverty level, but total out-of-pocket costs can never exceed 5% of family income. For beneficiaries paying standard Medicaid copayments, services cannot be withheld if you can’t pay, though you may still be billed for the amount owed. If your state has established “alternative” copayment structures with higher amounts, services can potentially be denied for nonpayment, so it’s worth understanding which cost-sharing rules apply to you.
For dual eligibles, Medicaid often covers the Medicare copayment for CCM services, meaning you may owe nothing out of pocket.
How to Find Out What Your State Covers
The fastest way to determine your specific coverage is to call the member services number on your Medicaid card. Ask whether your plan includes chronic care management, care coordination, or case management services for people with multiple chronic conditions. These terms are sometimes used interchangeably at the state level even though they have distinct meanings under Medicare.
If you’re enrolled in Medicaid managed care, your plan’s member handbook will list covered benefits. Look for sections on care coordination, disease management, or health home services. If you’re in a fee-for-service Medicaid program without managed care, your state Medicaid agency’s website will outline which care management services are available and whether you need a referral.
Your primary care provider’s office can also help. Many practices that offer CCM to Medicare patients are familiar with the equivalent Medicaid pathways in your state and can tell you whether they’re able to bill for those services on your behalf.