The Medicare patients who already use Carbon Health's primary care sites carry the conditions Medicare pays to manage between visits: hypertension, type 2 diabetes, chronic kidney disease and heart failure. This is the 24-month plan to bill for that work inside CarbyOS, with CoachCare staffing the program, switched on one primary care site at a time, with no capital and no new headcount.
Two counts, two jobs. The headline is 1,298 unique patients at month 24; the enrollment chart and the Scenario Explorer show 1,991 active program enrollments, because a patient on both RPM and CCM is one patient and two enrollments.
A primary care footprint in the Bay Area, Boston and central New Jersey, a Medicare population whose claims show the conditions remote care manages best, an EHR the company built and certified itself, and a Shared Savings Program contract in Massachusetts that rewards keeping those patients out of the hospital. What is missing is the service line.
Thirteen sites in the Bay Area, one in Roseville, five in Boston, five in central New Jersey and one in Puyallup offer primary care today, inside a network of 81 clinics across eight states. Every one of them is a place a Medicare patient can be enrolled.
CY2024 Medicare claims for clinicians billing at Carbon Health addresses show an average age of 73.5, hypertension in 64% of beneficiaries, diabetes in about one in four, chronic kidney disease in 18% and heart failure in 13%.
The Massachusetts professional corporation appears on the CMS PY2026 Shared Savings Program participant file inside a BASIC-track ACO, so care-management work at the five Boston sites counts toward shared savings as well as fee-for-service revenue.
The in-house EHR carries a September 2025 ONC certification with a standardized FHIR R4 API, transitions-of-care and Direct messaging criteria. The program integrates with the chart the clinicians already use; nobody changes systems.
One structural fact completes the picture: no remote patient monitoring or chronic care management program is visible at meaningful scale in CY2024 Medicare claims for any Carbon Health clinician. A remote-monitoring platform and a connected diabetes clinic were part of the company in 2021 and 2022; neither operates today. The panel that would have used them is still here, and so are the conditions.
Three things line up for a multi-site primary care operator in 2026: richer remote care billing, some of the highest care-management rates in the country at the San Francisco locality, and a program model that needs neither capital nor a hiring plan to start.
New CPT codes 99445 (2–15 days of device data) and 99470 (the first 10 minutes of management) remove the 16-day floor that used to block episodic monitoring. A blood-pressure titration or a post-discharge window is now cleanly billable next to the standard monthly RPM stack.
At the San Francisco locality, chronic care management pays $80.42 for the first 20 minutes and $62.10 for each additional 20, and device supply pays $73.14 a month. The same program at the same census returns more here than almost anywhere in the country, which is why the forecast on this page prices at list.
Enrollment outreach, care managers, devices and billing preparation are CoachCare's payroll, and fees are per active patient per month. The program starts at the first primary care site with no build cost and no hiring plan, and the same contract covers every site that follows.
A named service line with its own P&L and scorecard, following the multi-chronic Medicare patient the primary care sites already know, inside CarbyOS. The panel runs on RPM and CCM, with transitional care at every hospital discharge the clinics learn of. The professional corporation that bills in each state owns the program, its patients, its protocols and its revenue; CoachCare is the engine underneath it.
| Service | Codes | CY2026, San Francisco locality | Use across the panel |
|---|---|---|---|
| Chronic care management | 99490 · 99439 | $80.42 + $62.10 add'l | The longitudinal wrapper; two or more chronic conditions |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $29.95 setup · $73.14/mo | Hypertension, diabetes and heart-failure cohorts; 99445 opens 2–15-day windows |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $65.26 + $50.66 add'l · $32.81 | Monthly review, titration, escalation |
| Transitional care management | 99495 · 99496 | Per discharge | Every hospital or observation discharge the clinics learn of; not in the forecast below |
| Advanced primary care management | G0556 · G0557 · G0558 | $19.79 · $66.08 · $143.79/mo | Named as the next lever for the Boston sites; not in any figure on this page |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 94103 (Noridian, California locality 05), the basis the Value Analysis below is priced on. The Boston and New Jersey sites bill at their own localities.
CarbyOS is ONC-certified with a standardized FHIR R4 API, application access, transitions-of-care documents and Direct messaging. CoachCare integrates over those interfaces: eligible-patient flags and referral orders leave the chart, monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The integration is scoped in a workshop with the clinical informatics team and typically runs about four to six weeks, alongside onboarding.
typical integration window for a certified FHIR EHR, run in parallel with onboarding, training and care-team assignment.
a clinician flags an eligible patient and submits the referral from inside CarbyOS; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the company's own revenue cycle already runs. No PDFs, no re-keying.
The Value Analysis shows the program pays. This is how it stays safe. Every blood pressure, weight or glucose reading and every CCM check-in routes through the same protocol, so the practice sees signal rather than noise, and the clinicians keep clinical control.
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. 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 site 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 clinician's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the practice is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
Any emergency room visit or hospitalization in the last 60 days triggers three touches inside two weeks. For an operator whose urgent care sites see the visit that precedes many admissions, and the visit that follows a discharge, that trigger fires on the company's own data. When the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days. That cadence is where the modeled 136 avoided hospitalizations over 24 months come from.
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 site.
Close the episode or extend it; anything trending is escalated through the engine above.
A 24-month forecast for the RPM + CCM stack: a 5,500-patient Medicare panel across the 25 primary care sites with 4,400 in scope for Year 1, 40 referring clinicians plus CoachCare's enrollment outreach, San Francisco locality rates, and the CarbyOS integration, at CoachCare's list pricing. Shared-savings upside, TCM and APCM are not in these numbers.
| Program | Net reimbursement | CoachCare fees | Net to practice |
|---|---|---|---|
| RPM: devices, data and management | $2,582,422 | $1,344,639 | $1,237,783 |
| CCM: chronic care management | $2,616,479 | $1,282,410 | $1,334,069 |
| Implementation, CarbyOS integration and outreach | — | $74,979 | −$74,979 |
| 24-month total | $5,198,901 | $2,702,028 | $2,496,873 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the practice and never deducted from its margin. | |||
24-month practice margin: 48.0% of net reimbursement (Year 1 47.6%, Year 2 48.3%).
Year 1 is $992,701 net to the practice on $2,085,859 of net reimbursement; Year 2 is $1,504,172 on $3,113,042. Month 1 is $325 after the one-time setup; every month after it is larger.
Recurring professional-fee volume over 24 months, generated inside CarbyOS.
Blood pressure and weight, a continuous picture of the hypertension and diabetes cohorts between visits.
About $2.04M in acute-care cost that never gets spent, at $15,000 per admission. In Massachusetts, that is shared-savings arithmetic.
About 34,581 care-team hours of monitoring, outreach and documentation carried by the service line, not by clinic staff.
RPM reaches its ceiling of 1,001 enrollments in month 7 and CCM its ceiling of 990 in month 9. From there the census holds at 1,991 active enrollments, 1,298 unique patients. The binding constraint on this forecast is the size of the longitudinal Medicare panel, not outreach capacity. That is the constraint a company with 81 clinics and 25 primary care sites is best placed to relax.
| Program | Enrollment ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 1,001 | 4,400 in scope × 65% eligible × 35% acceptance | Month 7 |
| CCM | 990 | 4,400 in scope × 75% eligible × 30% acceptance | Month 9 |
| At month 24 | 1,991 | Active program enrollments = 1,298 unique patients | — |
Eligibility is set for an adult primary care Medicare panel. Every point of eligibility or acceptance the company's own chart data supports beyond these raises the ceiling, and the forecast, directly.
The first is the site list. Each primary care location brings its own Medicare panel with the same condition mix, and because the service line runs at a 48.0% margin with CoachCare carrying the staffing, a site inherits the program the month it is switched on rather than building one. The second is conversion. Medicare patients who use Carbon Health for urgent care and have no primary care relationship are the largest untapped pool in the network; every one who is offered a primary care home and monthly care management enlarges the panel this forecast runs on. The Scenario Explorer above is the sizing tool for either: put in the panel, read off the forecast.
Advanced Primary Care Management (G0556–G0558) is Medicare's bundled monthly payment for the panel this program manages, and its value-model requirement is one the Massachusetts professional corporation already meets through its Shared Savings participation. It carries zero dollars on this page. Once real enrollment data exists at the Boston sites, the CCM-versus-APCM mix there is the first design decision to make together.
CoachCare operates as the service line's engine while the practice's clinicians govern protocols and every clinical decision. Full-service delivery means launch needs no new headcount; the CarbyOS integration runs in parallel with onboarding, and the first enrollments follow the first referral orders at the Bay Area sites.
Integration workshop with clinical informatics, FHIR and Direct connections built and tested; named program lead; contracting with the professional corporation that bills in each state; P&L and scorecard; billing configuration with the revenue cycle team; protocol sign-off for the hypertension, diabetes and kidney pathways.
CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts at the 13 Bay Area sites; CoachCare's enrollment outreach working the sites in sequence; TCM and the urgent-care follow-up cadence live from day one.
RPM reaches its modeled ceiling in month 7 and CCM in month 9; monthly scorecard to the executive team; the Boston and central New Jersey sites switched on with the same protocols and their own localities.
Re-validate eligibility against chart data, decide the CCM-versus-APCM mix for the Boston sites, align Massachusetts reporting with the ACO's quality and cost measures, and turn urgent-care-only Medicare patients into primary care panel members.
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, priced at the San Francisco locality amounts the forecast runs on rather than national averages.
The proposals reach the remote-monitoring family only. Chronic care management is not in them, and on this forecast CCM carries $2,616,479 of the $5,198,901 in 24-month net reimbursement. Its own amounts move by about two points, so $52,428 of the $323,855 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 MSO-style arrangement in which CoachCare manages the staffing while the professional corporation owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months.
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 colour can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Noridian California locality 05 amounts, non-facility, on this panel's own billing mix. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B, so the movement can be read without a locality in the way. The repricing above uses San Francisco amounts; the two bases do not reconcile to the dollar, by design.
| 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 CY2028.
Comments on CMS-1848-P are due 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.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this partnership fits Carbon Health specifically, not remote care in general.
CoachCare runs bi-directional integrations with the major certified EHRs and connects to a certified FHIR R4 endpoint the same way. Eligibility flags and orders leave CarbyOS, vitals, documentation and billing-ready claims come back into it. No second system for clinicians, no re-keying for the revenue cycle team, and no pressure to change platforms.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. Every primary care site inherits a running program the month it is switched on, at a 48.0% margin, without a hiring cycle. That is how a program built once travels across 25 sites in three regions.
Every urgent care visit by an enrolled patient fires the three-touch cadence, every hospital discharge the clinics learn of becomes a TCM episode, and critical readings escalate through one engine whose urgent policy supersedes any preference. A network that sees the visit before the admission is the right shape for this program.
Fewer ED visits and admissions among attributed patients at the Boston sites are shared savings. The monthly touches that generate care-management revenue are the same touches that produce them. One program, both ledgers, with the fee-for-service margin funding it while the ACO benefit accrues.
The clinicians set the protocols, sign the care plans and make every clinical decision; the claims go out under the entity that treats the patient in each state. CoachCare supplies staff, devices, platform and billing preparation under that governance, which is the arrangement a multi-state operator needs.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. If the census does not build, CoachCare does not get paid, which is why the plan is measured twice before it goes to paper. The forecast, the Disclosures and the workbook behind this page are yours to keep either way.