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Medicare Care Management: Planning, Coordination, and Caregiver Training

Adapted from Your Medicare Benefits, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

Advance care planning

Advance care planning involves discussing and preparing for care you would get in the future if you need help making decisions for yourself. Part B covers voluntary advance care planning as part of your “Welcome to Medicare” and yearly preventive “Wellness” visits. Medicare may also cover this service as part of your medical treatment.

As part of advance care planning, you may choose to complete an advance directive. This important legal document records your wishes about medical treatment in the future, if you aren’t able to make decisions about your care.

Advance directives include 2 parts:

1. Your health care proxy (sometimes called “durable power of attorney”) names someone you trust to make decisions about your health if you can’t. 2. Your living will describes which treatment(s) you want if your life is threatened, including dialysis, breathing machines, resuscitation, and tube feeding. It also states if you want your organs or tissues donated after you die.

You can talk about an advance directive with an attorney or your health care provider, and they can help you prepare your documents. You can update your advance directive at any time.

Costs You pay nothing if your doctor or other health care provider accepts assignment and this planning is part of your “Welcome to Medicare” or yearly “Wellness” visit. If you get it as part of other medical treatment, the Part B deductible and coinsurance apply.

Things to know Consider carefully who you want to speak for you and what direction you want to give. You have the right to carry out your plans as you choose without discrimination.

More information

  • Go to “Preventive visits” on pages 93–95 for more information about “Welcome to Medicare” and yearly “Wellness” visits.
  • Visit Medicare.gov/coverage/advance-care-planning.
  • For help with advance directives, visit the Eldercare Locator at eldercare.acl.gov or contact your state health department at usa.gov/state-health.

Advanced Primary Care Management services

Advanced Primary Care Management is a patient-focused approach to care. Part B covers Advanced Primary Care Management services to help your doctor and other health care providers coordinate and tailor care to your needs each month.

Health care providers who offer Advanced Primary Care Management services take extra steps to actively manage all your health care needs. When you get these services, you and your primary care provider (or care team) agree that they’ll be your main point of ongoing care. They’ll talk to you about your care plan and coordinate all your health care needs, including care you get from other doctors, hospitals, and providers.

Providers that offer these services must provide you with:

  • 24/7 access to your care team or provider through the phone, an online portal, email, and virtual check-ins
  • Chronic care management
  • A personalized care plan that lists your current conditions and treatments
  • Comprehensive care coordination to quickly connect you with specialists and other providers
  • Transitional care between health care settings (like follow-up care after you’re discharged from a hospital)
  • Medication management
  • Behavioral health integration services (including the Psychiatric Collaborative Care Model)

Costs After you meet the Part B deductible, you pay 20% of the Medicare-approved amount. Many people who have both Medicare and Medicaid pay nothing for these services.

Things to know

  • Check with your primary care provider to make sure they offer these services. Then, give your provider verbal or written consent to be your main point of care for all your health needs. They’ll document your consent on your medical record. You must also have an initial visit with your provider unless:
  • You’ve gone to the provider or another provider in the same practice within the last 3 years.
  • You got another type of care management (like chronic care management) from the provider or another provider in the same practice within the last year.
  • You can stop getting these services at any time. Talk to your provider to stop participating.

More information

  • Go to “Behavioral health integration services” on page 13.
  • Visit Medicare.gov/coverage/advanced-primary-care-management-services.

Chronic care management services

If you have 2 or more serious chronic conditions (like arthritis or diabetes) that you expect to last at least a year, Part B may pay for a doctor or other health care provider to help manage your care for those conditions.

Costs After you meet the Part B deductible, you pay coinsurance for these services.

Things to know

  • Chronic care management includes:
  • A comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other information about your health.
  • 24/7 access for urgent care needs.
  • Support when you go from one health care setting to another.
  • Review of your medicines and how to take them.
  • Help with other chronic care needs.
  • Your health care provider will ask you to sign an agreement for you to get this set of services on a monthly basis. If you agree to get these services, your provider will prepare a care plan for you or your caregiver that explains the care you need and how your providers will coordinate it.
  • To get started, ask your providers if they offer chronic care management services.

More information

  • Go to:
  • “Advanced Primary Care Management services” on pages 9–10.
  • “Caregiver training services” on pages 18–19.
  • “Principal illness navigation services” on pages 95–96.
  • Visit Medicare.gov/coverage/chronic-care-management-services.

Principal care management services

Principal care management includes disease-specific services to help your doctor or other health care provider manage your care for a single, complex chronic condition that puts you at risk of hospitalization, physical or cognitive decline, or death. Part B covers principal care management services if you have one chronic high-risk condition that you expect to last at least 3 months (like cancer) and you aren’t being treated for any other complex conditions. Your provider will create a disease-specific care plan and continuously monitor and update it, including any changes to the medicines you take.

Costs After you meet the Part B deductible, you pay 20% of the Medicare-approved amount.

More information

  • Go to “Principal illness navigation services” below.
  • Visit Medicare.gov/coverage/principal-care-management-services.

Transitional care management services

Part B may cover transitional care management services if you’re returning to the community after an inpatient stay at certain facilities, like a hospital or skilled nursing facility. You’ll also be able to get an in-person office visit within 2 weeks of your return home.

Costs After you meet the Part B deductible, you pay coinsurance for these services.

Things to know The health care provider who’s managing your transition back into the community will work with you, your family, caregivers, and other providers to coordinate and manage your care for the first 30 days after you return home.

The health care provider may also help you:

  • Review information on the care you got in the facility
  • Get information to help you transition back to living in the community
  • Get referrals or make arrangements for follow-up care or community resources
  • Schedule appointments
  • Manage your medications

More information

  • Go to “Caregiver training services” on pages 18–19.
  • Visit Medicare.gov/coverage/transitional-care-management-services.

Caregiver training services

If you’re a caregiver, this training teaches you skills to help care for someone with Medicare, including how to:

  • Give medications and help with daily tasks
  • Move the patient safely
  • Communicate effectively with the patient
  • Better understand and manage the patient’s medical condition(s)
  • Give personalized care and emotional support
  • Prevent bedsores and infections, and care for wounds

Part B covers caregiver training services if both of these conditions apply:

  • The training focuses on helping the patient meet the health and treatment goals they set with their doctor or other health care provider.
  • The patient needs a caregiver’s help for their treatment to succeed.

Costs After you meet the Part B deductible, you pay 20% of the Medicare-approved amount.

Things to know

  • If a health care provider determines that caregiver training is appropriate for a patient’s treatment plan, the caregiver can get individual or group training sessions from the provider without the patient present.
  • Caregiver(s) can get this training from Medicare providers, including:
  • Doctors
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified nurse-midwives
  • Physician assistants
  • Clinical psychologists
  • Therapists (like physical, occupational, and speech)

More information

  • Go to:
  • “Chronic care management services” on page 22.
  • “Cognitive assessment & care plan services” on pages 23–24.
  • “Home infusion therapy services, equipment, & supplies” on pages 54–55.
  • “Hospice care” on pages 55–57.
  • “Telehealth” on page 108.
  • Visit Medicare.gov/coverage/caregiver-training-services.

Community health integration services

Your doctor or other health care provider might find that certain conditions (like limited access to food or your living environment) are impacting your health or access to care. In these cases, Part B covers community health integration services to address your needs and help your health care provider diagnose or treat your medical conditions. Some community health integration services include:

  • An assessment to better understand your life story
  • Care coordination
  • Health education
  • Patient self-advocacy training
  • Health system navigation
  • Social and emotional support

You must have an initial visit with your provider (separate from your yearly “Wellness” visit) before you can start getting community health integration services. After your initial visit, you can get these services every month. Your provider or their staff can give you the community health integration services or refer you to other trained personnel (including community health workers) for the services.

Costs After you meet the Part B deductible, you pay 20% of the Medicare-approved amount.

More information Visit Medicare.gov/coverage/community-health-integration-services.

Source and further reading

Your Medicare Benefits — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.

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