What Is Connected Care? A Complete Guide to Medicare's Technology-Enabled Care Programs

Connected care describes a model of health care delivery that uses communication technologies, remote monitoring devices, and structured care coordination to extend the clinical relationship beyond the walls of a medical practice. The term encompasses a range of Medicare-reimbursable service lines, including Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Principal Care Management (PCM), Behavioral Health Integration (BHI), Advanced Primary Care Management (APCM), and emerging innovation models such as the ACCESS program.

The core premise: patients with chronic conditions require ongoing, proactive management between office visits. Traditional fee-for-service medicine compensates physicians primarily for face-to-face encounters. Connected care programs create billing pathways for the work that happens in between those encounters. Phone calls to adjust medications, review of transmitted blood pressure readings, coordination with specialists, behavioral health screenings, care plan updates, medication reconciliations, and patient education sessions can all be reimbursed under the appropriate connected care program.

The Centers for Medicare & Medicaid Services (CMS) has steadily expanded the connected care framework since 2015, when it began separately reimbursing non-face-to-face chronic care management under CPT code 99490. Each subsequent Physician Fee Schedule final rule has added new codes, refined documentation requirements, and broadened the eligible provider and patient populations. The trajectory reflects a broader shift in U.S. health policy toward value-based care, in which providers are rewarded for health outcomes and care quality rather than the volume of services delivered.

Connected care matters because chronic disease accounts for the vast majority of Medicare spending. According to CMS Chronic Condition Data Warehouse statistics, over two-thirds of Medicare fee-for-service beneficiaries have two or more chronic conditions. Beneficiaries with multiple chronic conditions account for a disproportionate share of hospitalizations, emergency department visits, and total per-beneficiary spending. The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC) reports that more than half of U.S. adults have at least one chronic condition, and chronic diseases are the leading drivers of health care costs in the United States.

Connected care programs attempt to intervene upstream, catching deterioration early, reinforcing medication adherence, addressing behavioral health needs, and reducing avoidable acute care utilization. The evidence base for these interventions continues to grow across peer-reviewed literature, with studies published in journals including JAMA, Annals of Internal Medicine, and Health Affairs examining the cost and quality implications of remote monitoring and care management.

**Sources:** CMS Chronic Conditions Chartbook (2012 ed.); CDC Chronic Disease Indicators (2022-2024 refresh); 42 U.S.C. § 1395; CMS Medicare Physician Fee Schedule final rules, 2015-2026.

Connected Care