Hana Health
All posts
Care Management
Hana Health
Care ManagementNovember 2, 2026

CCM Patient Cost Sharing in 2026: Copays, Medigap and Waivers

Matteo

Updated November 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

CCM cost sharing is the part of the monthly Chronic Care Management fee that a Medicare patient owes after Medicare pays its share. Under Original Medicare, the Part B deductible ($283 in 2026) and 20% coinsurance both apply. On 99490, which pays $66.13 nationally in 2026, that's about $13.23 a month once the deductible is met. Medigap or Medicaid often covers that share.

Key facts

What does a Medicare patient pay for CCM?

In Original Medicare, a patient pays the Part B deductible first and then 20% of the Medicare approved amount for each CCM claim. CCM isn't free to the patient just because no visit happens. Medicare.gov lists it as a monthly Part B service with the standard deductible and coinsurance.

The deductible is a yearly amount. It's $283 in 2026, and it resets every January. A patient who hasn't had other Part B claims this year may owe the full CCM allowed amount until the deductible is used up. After that, Medicare pays 80% and the patient owes 20%.

This is why CMS tells practices to say so up front. The MLN booklet notes that cost sharing applies even though CCM is mostly non face to face, and that some patients have Medigap to help cover it. Medicare Advantage is different. Plans set their own cost sharing and rules, so this article covers Original Medicare only. Check the plan before you quote a number.

One more limit worth saying out loud. I couldn't find CMS or peer reviewed data that isolates cost sharing as the reason patients leave CCM, so treat any claim that it's the main driver as unproven. If you want the retention picture, start with why patients drop out of CCM.

How much is the copay on each CCM code?

For 99490, the patient's 20% share is about $13.23 a month once the deductible is met, and Medicare pays the other $52.90. The math is the allowed amount times 0.20. Here's the worked example, using national 2026 amounts before geographic adjustment.

  • 99490 (first 20 minutes of clinical staff time): 1.98 RVUs × $33.4009 = $66.13. Patient share at 20% is $13.23. Medicare pays $52.90.
  • 99491 (first 30 minutes of the billing practitioner's own time): $89.18. Patient share at 20% is $17.84.
  • 99487 (first 60 minutes of complex CCM): $144.29. Patient share at 20% is $28.86.
  • A full year of 99490: 12 × $13.23 = $158.76, or about $159, if the patient is billed every month and has met the deductible.

Your own allowed amount will differ by locality, because Medicare adjusts each RVU by geography. The national figures come from the CMS physician fee schedule files, so check the CMS Physician Fee Schedule lookup for your locality.

Which code you bill depends on who did the work and how many minutes you logged. If you need that part, see the CCM billing codes guide.

Who doesn't owe CCM cost sharing?

Three groups usually don't feel the 20%: patients with Medigap, patients who are Qualified Medicare Beneficiaries, and most dually eligible patients. CMS describes each of these in its CCM toolkit and its QMB billing notice.

Medigap plans provide wrap around coverage of CCM cost sharing, according to the CMS toolkit, and many patients have Medigap or other supplemental insurance. For those patients the copay is paid by the supplement, not out of pocket.

Qualified Medicare Beneficiaries are a different case, and it's a legal one. Federal law prohibits Original Medicare and Medicare Advantage providers from billing QMBs for Part A or Part B deductibles, coinsurance or copayments. That applies even if Medicaid pays nothing. CMS says providers must put processes in place to identify QMB status.

The CMS toolkit adds that most dually eligible patients, meaning Medicare and Medicaid, aren't responsible for cost sharing. Don't assume, though. Verify each patient's status when you check eligibility, and record what you found.

Do you have to tell patients about cost sharing before CCM starts?

Yes. CMS requires written or verbal consent before you bill CCM, and the patient has to be told about their possible cost sharing responsibilities. The MLN booklet lists five items to explain and document in the chart.

  • The availability of CCM services.
  • Their possible cost sharing responsibilities.
  • That only one practitioner can provide and bill CCM in a calendar month.
  • Their right to stop CCM at any time, effective at the end of the calendar month.
  • That you explained all of this and whether the patient accepted or declined.

Consent is needed once, unless the patient switches to a different CCM practitioner. That makes the first conversation matter. Say the number out loud. "About $13 a month after your deductible, and your Medigap plan may cover it" is a better sentence than "there may be cost sharing."

The full consent and care plan checklist is in our CCM consent and care plan requirements guide.

Can a practice waive the CCM copay?

Not as a routine practice. OIG's Special Fraud Alert on routine waiver says that routinely waiving copayments and deductibles can lead to false claims and Anti-Kickback Statute violations. The exception is a particular patient's financial hardship, used occasionally and case by case, with a good faith effort to collect otherwise.

OIG lists warning signs, including ads that say "No Out Of Pocket Expense" or "Insurance Accepted As Payment in Full," and collecting copays only from patients who have Medigap. If you waive for hardship, document how you decided.

Two honest limits. The alert dates to 1991 and was republished in the Federal Register in 1994, so it's older than CCM, which Medicare began paying for separately in 2015. And it speaks mainly about charge based payment. Ask healthcare counsel how it applies to a fee schedule service like CCM before you write a policy. QMB patients are separate: you can't bill them, and you don't need a hardship reason.

What this means for your practice

Treat cost sharing as part of enrollment, not as a billing surprise. A few steps keep it clean.

  • Check eligibility first. Look for Medigap, QMB or Medicaid status, and a Medicare Advantage plan, before you pitch the program.
  • Put a plain number in your consent script, using your own locality's allowed amount.
  • Write one policy for hardship. Name who decides, what you ask for, and where you record it.
  • Don't promise "free." Promise value and be clear about cost.
  • Recheck every January, because the deductible and the fee schedule both change. The 2027 amounts take effect January 1, 2027.

HANA Health builds voice outreach that helps practice teams reach patients and walk through the enrollment and consent conversation, while the clinical team keeps ownership of the care plan and the billable work. You can see how that fits care management at HANA Remote. For the program basics, start with what chronic care management is.

Frequently asked questions

Does Medicare Advantage charge a copay for CCM?

It depends on the plan. Medicare Advantage plans set their own cost sharing and coverage rules, and the figures in this article apply to Original Medicare. Verify with the plan before you quote a number.

What if the patient hasn't met their deductible?

Then the patient may owe the full allowed amount until the remaining deductible is used up. With a $283 deductible and a $66.13 claim, a patient with no other Part B claims that year would owe all $66.13 on the first claim. QMB patients are the exception, because you can't bill them.

Is the copay the same every month?

The percentage is. It's 20% of the allowed amount after the deductible. The dollar amount changes with the code you bill and your locality, and the deductible resets each January.

Does the copay change when clinical staff do the work instead of the physician?

The coinsurance rate doesn't change. The code does. 99490 is built on clinical staff time and pays less than 99491, which needs the billing practitioner's own time, so the patient's 20% share is smaller on 99490.

What should the consent note say about cost?

It should show that you told the patient about possible cost sharing and that they accepted or declined. CMS also wants the other four items in the chart. Consent is needed once unless the patient changes CCM practitioners.

Sources

  1. Medicare.gov. Chronic care management services. Coverage and costs page.
  2. CMS Medicare Learning Network. MLN909188, Chronic Care Management Services. June 2025.
  3. CMS. Chronic Care Management Toolkit. Resources for health care professionals.
  4. CMS Medicare Learning Network. MLN7936176, Prohibition on Billing Qualified Medicare Beneficiaries. September 2025.
  5. HHS Office of Inspector General. Special Fraud Alerts, including Routine Waiver of Copayments or Deductibles Under Medicare Part B. Federal Register, December 19, 1994 (alert issued May 1991).
  6. CMS. 2026 Medicare Parts A and B Premiums and Deductibles. November 14, 2025.
  7. CMS. CY 2026 Payment Policies Under the Physician Fee Schedule, CMS-1832-F, 90 FR 49266. Federal Register, November 5, 2025.
  8. CMS. Physician Fee Schedule. National payment files and lookup.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill.

If you want to talk through how to run the enrollment call and the cost sharing conversation, you can book a discovery call.