South Central Primary Care screens for depression, tobacco use and BMI at top-national-quartile rates and holds two 2026 national quality badges. The measure that stays stubborn is hypertension control — 58.7% against a 69.1% national health-center average, across a 3,045-patient hypertension registry — and it is stubborn because blood pressure is decided in the 90 days between appointments. Since January 1, 2026, the between-visit work that moves it bills code-by-code on top of the PPS encounter. This is the business case for pointing the health center's outreach machine at it.
The headline counts 423 unique patients in active remote care at Month 24. The enrollment chart and the Scenario Explorer show 648 active program enrollments (services): CCM and APCM cannot be billed for the same patient in the same month, so the 172 CCM and 150 APCM enrollments are 322 distinct care-management patients. Most of the 326 RPM enrollments sit inside those cohorts as a second program on the same patient, and the balance are monitoring-only — together, 423 unique patients. Program enrollments are never labeled “patients.”
Health centers report clinical quality to HRSA every year and are ranked against every health center in the country. South Central Primary Care's CY2025 report card puts four screening measures in the best-performing national quartile, and HRSA's 2026 Community Health Quality Recognition names it a National Quality Leader twice.
Top national quartile — alongside tobacco screening at 95.0%, BMI screening at 94.5%, and HIV screening. When this organization decides to reach its patients, it reaches them.
HRSA's Community Health Quality Recognition for 2026: National Quality Leader in Behavioral Health and in Diabetes Health, on top of AAAHC accreditation and PCMH recognition.
The Medicare line has grown every single year since 2021 — 1,017 patients then, 1,432 now. The population these programs bill on keeps getting larger.
Sixteen HRSA-registered sites spanning Irwin, Coffee, Ben Hill, Atkinson, Berrien and Lowndes counties, with a mobile unit that extends the footprint into Cook County. A Section 330 grantee since 1992, funded through 2030 with no program conditions.
School-based clinics, a mobile health unit running screenings across seven counties, and outreach staff certified as application counselors who walk patients through paperwork every day. That is exactly the muscle a remote-care program runs on.
An in-house pharmacy in Valdosta, home delivery, and a contract-pharmacy network across the service area. Medication changes a monitoring program triggers get filled by the health center's own counter.
The screening measures respond to visits, and the visits happen. Hypertension control does not respond to visits alone — a blood-pressure reading taken four times a year cannot manage a disease that moves week to week. That is why the same organization that screens in the top quartile sits in the bottom quartile on blood-pressure control, with 3,045 hypertensive patients on its registry.
The panel these programs bill on, from the health center's own CY2025 federal report — up 41% since 2021, growing every year without exception.
524 of the 1,432 Medicare patients also carry Medicaid. That mix is what makes the top APCM tier — the one built for qualified Medicare beneficiaries — pay more here than in a typical practice.
Up from 810 in 2021. The oldest segment of the panel is growing the fastest, and it carries the chronic-disease burden these programs are built for.
G0511 — the single bundled code that paid health centers one flat amount for roughly twenty distinct care-management services — is gone. Since January 1, 2026, federally qualified health centers bill the individual CCM, RPM and APCM codes, each separately payable in addition to the PPS encounter rate.
PPS still pays for the visit. Care management and remote monitoring pay on top of it rather than folding into it, so a remote-care program does not cannibalize the encounter.
These codes pay health centers at national fee-schedule amounts with no geographic adjustment. The forecast on this page prices them at the lower Georgia-locality schedule instead — about six percent under the national amounts — so the national basis is headroom, not an assumption.
Each program now needs its own time capture and its own documentation, every month, for every enrolled patient. That is the operational cost of the change, and it is the part CoachCare absorbs.
South Central Primary Care is a PY2026 participant in Accountable Care Coalition of Georgia, a Medicare Shared Savings Program ACO running in the ENHANCED track — the two-sided track, where the ACO shares losses as well as savings — under an agreement period that began January 1, 2024. Under two-sided risk, an uncontrolled hypertension registry is claims exposure as well as a quality gap.
Medicare assigns beneficiaries based on where they receive primary-care services, and documented monthly care management is primary care delivered twelve times a year. A patient managed monthly is a patient whose attribution — and whose annual revenue — stays home.
In the ENHANCED track, every hospitalization that does not happen is money on the ACO's reconciliation. The 41 avoided hospitalizations in this forecast — roughly $616,000 of acute spend — accrue to exactly the number the ACO is judged on.
Hypertension control sits in both scoreboards — the UDS report card and the ACO quality set. The same between-visit readings that move the federal measure move the shared-savings result, from one data stream.
Modeled across the 1,432 Medicare and dual-eligible patients in the health center's CY2025 panel — the population where these codes pay at Medicare rates. CoachCare supplies the devices, the enrollment staff, the monitoring hours and the documentation. The health center supplies the panel and the clinical decisions.
Remote physiologic monitoring. Blood-pressure cuffs and glucose meters that transmit on their own — 99453 setup, 99454 device supply, 99457 and 99458 treatment management, plus the CY2026 short-window codes 99445 and 99470. Reaches 65% of the panel and stacks with either care-management rail — and it is the program aimed squarely at the blood-pressure measure.
Chronic care management. Monthly non-face-to-face management for patients with two or more chronic conditions — which, in a panel where 3,045 patients carry hypertension and 1,552 carry diabetes, is most of the Medicare population. 99490 and 99439.
Advanced primary care management. No minute thresholds and no time sheets — a monthly per-patient payment tiered by complexity. G0556, G0557 and G0558, where the top tier pays most for qualified Medicare beneficiaries who also carry Medicaid. 524 of the health center's 1,432 Medicare patients — 36.6% — are dual-eligible, more than double the national share, which is what makes this panel's APCM economics unusual.
Enrollment is built for this footprint: the on-site specialist works the highest-volume adult site while telephonic outreach covers the rest, the mobile unit and school-based network extend reach across seven counties, and enrollment materials follow the panel's languages — including the Spanish-speaking farmworker communities the health center already serves.
South Central Primary Care charts in eClinicalWorks, and CoachCare builds on eCW's own workflows — so the care team enrolls and monitors patients without learning a second system. Readings, documentation and claims all land in the chart the clinicians already work in.
Enrollment flags and trigger ordering by service sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on the health center's behalf, and enrollment status is visible in eCW in real time.
Bi-directional at intake, so the care team starts with the same problem list, medications and history the clinic has.
Blood pressure, weight and glucose readings post to the patient record as integrated vital reports rather than attachments nobody opens.
Evidence of Care, vitals and care plans attach to the chart every month. Under the CY2026 individual-code rules each program needs its own time capture and its own documentation, and this is what substantiates the billed time when a payer asks.
Claims are created by the CoachCare billing engine. CoachCare is the only care-management application integrated with eClinicalWorks that provides automated claims creation, which removes the manual per-patient, per-month claim step entirely.
The economics prove the service line pays. This is what keeps it safe — and what lets eleven busy clinicians delegate monitoring without inheriting noise.
The care team retakes it and screens for symptoms before anything escalates. A single high number is a measurement; a confirmed one is a finding.
A patient who feels fine with a critical reading still escalates. Feeling well is not a reason to wait.
Three readings at least an hour apart for blood pressure or glucose, or three within seven days for heart rate. Not a judgment call, and not a different threshold depending on who is working.
Voicemail and a callback attempt are logged, and a critical value or confirmed trend escalates anyway. Silence never closes a case.
Emergencies go to 911. Non-critical findings go to a named member of the practice team. Stable and resolved goes into the record as an FYI, so the clinic is not paged for readings that resolved themselves.
Vital, findings, method of contact, who was reached, outcome, and follow-up. That record is also what substantiates the billed time.
A 24-month forecast across the 1,432-patient Medicare and dual-eligible population, 11 referring adult-medicine clinicians, one CoachCare-funded on-site enrollment specialist, telephonic enrollment, and CY2026 Georgia-locality fee-schedule rates. Medicare Advantage plans — the majority of this market — reimburse at a floor of 100% of the Medicare rate, with individual contracts setting their own terms for the care-management code families. Medicaid revenue, 340B pharmacy effects, transitional care management, shared savings and the dollar value of avoided admissions are not in these numbers.
| Program | Year 1 | Year 2 | 24‑Month |
|---|---|---|---|
| RPM net reimbursement | $207,287 | $350,481 | $557,768 |
| CCM net reimbursement | $158,791 | $218,096 | $376,887 |
| APCM net reimbursement | $91,391 | $107,055 | $198,446 |
| Total net reimbursement | $457,469 | $675,632 | $1,133,102 |
| CoachCare fees (incl. one-time) | $268,374 | $383,651 | $652,025 |
| Net to the health center | $189,095 | $291,981 | $481,077 |
| Margin to the health center | 41.34% | 43.22% | 42.46% |
Roughly $616,000 of avoided acute cost over 24 months. That value accrues to payers and to the ACO's two-sided reconciliation rather than to the health center's revenue line, so it is excluded from every figure above.
Blood pressure, weight and glucose readings arriving between visits, where the hypertension measure is decided.
Coded, documented and submitted with the time capture the CY2026 individual-code rules require.
About 3.9 full-time equivalents of care-management capacity, added without the health center hiring anyone.
The forecast above covers 1,432 Medicare and dual-eligible patients. South Central serves 7,142 Medicaid patients and 2,703 uninsured patients across the same counties. Everything the service line builds for Medicare — the device fleet, the enrollment staff, the escalation engine — is the same machine. What differs is the payment rail, and Georgia's is specific.
Georgia Medicaid reimburses health centers for face-to-face encounters; remote monitoring and care management are not separately payable inside the FQHC. That is exactly why the sequencing starts with Medicare — the rail that pays code-by-code from month one, at every site.
The UDS report card is all-payer: the blood-pressure program Medicare funds builds the protocols, staff and registry discipline that lift the measure for all 3,045 hypertensive patients — and the two national quality badges sit on exactly that kind of panel-wide performance. Better adherence also fills the scripts the in-house pharmacy dispenses.
Georgia's rural health transformation program — $218.8 million approved for its first year — is funding telemedicine and school-based health across the state, and no health center has been funded yet. A running remote-care program with measurable blood-pressure results is the strongest application a health center can file in the phases ahead.
Pull the exact Medicare and dual-eligible count from the practice management system, submit the eClinicalWorks interface request, and agree which site starts — the Valdosta adult-medicine site and the Ocilla flagship carry the panel's weight and are the natural candidates.
Enrollment flags and trigger orders built into the existing workflow, vital reports mapped to the chart, escalation routing set to the health center's own contacts, documentation templates mapped to the CY2026 individual-code requirements, enrollment materials in the panel's languages, devices staged, and the on-site enrollment specialist placed.
Enrollment begins in month 1 — there is no dormant onboarding period. Telephonic outreach, the school-based network and the mobile unit extend reach beyond the starting site from day one.
APCM reaches its ceiling in month 4, CCM in month 7 and RPM in month 10. From there the program grows with the panel itself — a Medicare line up 41% in four years — and the conversation turns to the quality measures, the state's rural program, and the ACO's next reconciliation.
Over 400 managed conditions.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims.
Over 100 million vitals recorded and more than 4 million care actions enabled.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline, and this is what they do to the forecast in this document — priced at South Central Primary Care's own Georgia locality amounts, not at national averages.
The proposals reach the remote-monitoring family only. Chronic care management and advanced primary care management are not in them — and on this forecast those two programs carry $575,333 of the $1,133,102 in 24-month net reimbursement. Their own amounts move by less than a percentage point to two points, so $9,766 of the $60,306 total sits outside the remote-monitoring arm.
Two contingencies are already in build. An unbundled arrangement — SaaS platform, device logistics and program enablement priced separately — and an MSO-style arrangement in which CoachCare manages the staffing while the health center 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 below are drawn on one shared dollar scale, so the red can be compared directly across them — and the same reduction lands against far more.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Palmetto GBA Georgia locality amounts (Rest of Georgia), non-facility, on this health center'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 Georgia locality amounts; these two bases will 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 therefore 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.