Care Management Models and Frameworks

Care management models and frameworks define the structural, procedural, and regulatory architecture through which health systems, payers, and community organizations coordinate clinical and social support for individuals with complex or chronic health needs. This page provides a reference-grade survey of the principal models in use across the United States, the regulatory codes and agency frameworks that govern their implementation, and the classification distinctions that separate one model from another. Understanding these distinctions matters because reimbursement eligibility, accreditation requirements, and outcome measurement all depend on which model a program formally adopts.

• Definition and scope
• Core mechanics or structure
• Causal relationships or drivers
• Classification boundaries
• Tradeoffs and tensions
• Common misconceptions
• Checklist or steps (non-advisory)
• Reference table or matrix
• References

Definition and scope

Care management, as defined by the Centers for Medicare & Medicaid Services (CMS), encompasses a set of activities designed to assist patients and their support systems in managing medical conditions more effectively. The definition is operationalized through specific billing codes—principally the Chronic Care Management (CCM) codes under CPT 99490–99491 and Complex Chronic Care Management under CPT 99487–99489—which impose specific time, staffing, and documentation requirements that function as de facto structural definitions.

A framework, by contrast, is the conceptual architecture that organizes how care management activities are sequenced, staffed, and measured. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination—a component of most frameworks—as "deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care."

The scope of care management in the United States spans at minimum four distinct delivery contexts: fee-for-service Medicare programs, Medicaid managed care programs governed by 42 CFR Part 438, commercial health plan programs regulated by state insurance commissioners, and community-based programs operating under the Accountable Health Communities model administered by CMS's Innovation Center (CMMI). Each context imposes different eligibility criteria, documentation standards, and outcome expectations, which is why no single universal framework applies across all settings. For a broader orientation to the field, the medical and health services topic context page provides foundational framing.

Core mechanics or structure

Regardless of the specific model, care management frameworks share five structural components that the Case Management Society of America (CMSA) identifies in its Standards of Practice for Case Management (2016, revised 2022):

1. Assessment — Systematic collection of clinical, functional, psychosocial, and social determinant data to establish a baseline profile.
2. Planning — Development of a person-centered care plan that specifies goals, interventions, responsible parties, and timelines.
3. Implementation — Activation of services, referrals, and patient education aligned with the care plan.
4. Monitoring — Ongoing tracking of patient status, adherence, and plan effectiveness using structured touchpoints.
5. Evaluation and transition — Formal reassessment of outcomes and, where applicable, transition to lower-intensity support or case closure.

The CMS Chronic Care Management service requires a minimum of 20 minutes of non-face-to-face clinical staff time per calendar month per beneficiary, documented in a structured electronic health record, as specified in 42 CFR § 410.26 and clarified in CMS's annual Physician Fee Schedule final rules.

The patient-centered care planning process sits at the center of all recognized frameworks, with interdisciplinary care teams providing the staffing architecture that converts plans into coordinated action.

Causal relationships or drivers

Three converging policy and financial forces drove the formalization of care management frameworks from the 1990s onward.

The chronic disease burden. The CDC's National Center for Health Statistics reports that 60 percent of U.S. adults have at least one chronic condition, and 40 percent have two or more (CDC, Chronic Disease Overview, 2023). This concentration of morbidity creates predictable, addressable utilization patterns that structured management can influence.

Value-based payment reform. The Affordable Care Act of 2010 (Public Law 111-148) created Medicare Shared Savings Programs (MSSP) and authorized CMMI, which has funded model testing across Accountable Care Organizations, bundled payments, and Primary Care First. These payment structures reward outcome improvements over volume, making care management infrastructure a financial necessity rather than an optional service enhancement. The value-based care and care management reference page details the payment mechanism linkages.

Risk stratification tools. The adoption of hierarchical condition category (HCC) scoring by CMS, and analogous risk scoring by commercial payers, created a legible method for identifying high-need, high-cost patients. Risk stratification in care management is now embedded as a mandatory upstream step in most model specifications, including those required under Medicaid managed care regulations at 42 CFR § 438.208.

Classification boundaries

Care management models in the United States fall into four primary categories distinguished by target population, time horizon, and organizational locus of control:

1. Disease-Specific Management Models — Focus on a single condition (e.g., diabetes, heart failure, COPD) with condition-specific protocols. The chronic disease care management model is the dominant form. Examples include NCQA's Diabetes Recognition Program standards and AHA/ACC heart failure staging protocols.

2. Population Health Management Models — Apply stratified interventions across an attributed panel of patients regardless of individual contact. Governed by payer contracts and HEDIS measures maintained by NCQA. The population health management reference addresses this model's scope.

3. Transitional Care Models — Time-limited interventions bridging inpatient and post-acute settings. The Coleman Care Transitions Intervention and the Naylor Transitional Care Model are two named, published models. CMS reimburses transitional care management via CPT 99495–99496 under the Physician Fee Schedule. See transitional care management for mechanism details.

4. Complex and High-Risk Case Management — Reserved for patients with 3 or more chronic conditions, functional limitations, and high predicted cost. CMS recognizes this tier through Complex CCM codes (CPT 99487–99489) requiring 60+ minutes per month of clinical staff time. CMSA and the National Association of Social Workers (NASW) both publish standards for this tier.

The distinction between care coordination vs. care management is a classification boundary frequently confused in practice; care coordination is a function embedded within care management, not a parallel system.

Tradeoffs and tensions

Standardization vs. individualization. Protocol-driven models (especially disease-specific) improve fidelity and measurability but reduce flexibility for patients with complex comorbidities or atypical presentations. CMSA's standards explicitly require individualized care plans, but CMS billing codes enforce time-based, activity-specific documentation that pushes programs toward standardized workflows.

Population breadth vs. intervention intensity. Programs that stratify broadly capture more patients but must deliver lower-intensity services per person. Programs that concentrate on the top 1–5% of risk tiers achieve higher per-patient intensity but miss the "rising risk" population where early intervention has the strongest preventive value—a tension documented in AHRQ's Closing the Quality Gap report series.

Clinician-led vs. community health worker (CHW) models. Registered nurse or licensed clinical social worker (LCSW)-led models satisfy CMS incident-to billing requirements but carry higher labor costs per beneficiary. CHW-led models reduce cost but are reimbursable under Medicaid only in states that have adopted Section 1905(a)(26) or State Plan Amendment pathways, creating geographic equity gaps. The social determinants of health in care management reference addresses how this tension interacts with non-clinical need.

Short-term metrics vs. long-term outcomes. Quality metrics required by NCQA HEDIS and CMS Star Ratings (e.g., HbA1c testing rates, medication adherence) measure process completion, not clinical outcome change. Programs optimized for metric performance may diverge from programs optimized for patient-centered outcomes as defined by PCORI's methodology standards.

Common misconceptions

Misconception: Care management and case management are synonymous.
Correction: Case management, as defined by CMSA, is one methodology within the broader care management landscape. Case management typically addresses episodic, high-acuity needs with a defined closure point. Care management frameworks often describe ongoing, longitudinal programs without a defined endpoint. CMS billing codes, NCQA accreditation standards, and CMSA's own standards treat these as distinct categories with different credentialing and documentation requirements.

Misconception: A care plan document constitutes a care management program.
Correction: A care plan is a required artifact within a care management framework, not the framework itself. CMS's CCM requirements specify that the plan must be electronic, accessible to the care team, and updated at defined intervals—but the plan alone does not satisfy the monitoring, implementation, or evaluation components that define the model.

Misconception: Care management reduces costs automatically.
Correction: AHRQ's evidence reviews and CBO analyses of ACA demonstration programs have found heterogeneous cost outcomes. Programs with weak risk stratification or insufficient intervention intensity have shown neutral or negative net cost effects. Cost reduction is an output of well-implemented frameworks applied to appropriately targeted populations, not an inherent property of the model category.

Misconception: Telehealth delivery is equivalent to in-person care management for all billing purposes.
Correction: CMS established distinct rules for telehealth-delivered CCM services, and parity between modalities is governed by annually updated Physician Fee Schedule rules and the specific statutory authority granted under the Consolidated Appropriations Act of 2023. The telehealth and remote care management reference covers these distinctions in detail.

Checklist or steps (non-advisory)

The following sequence reflects the structural elements common to formalized care management programs as documented in CMS program specifications, CMSA standards, and NCQA accreditation criteria. This is a reference inventory, not a clinical protocol.

Phase 1 — Program Infrastructure
- [ ] Define target population eligibility criteria (diagnosis codes, risk scores, payer contracts)
- [ ] Establish care team composition and scope-of-practice boundaries per state licensure
- [ ] Select or configure an electronic health record (EHR) that meets CMS structured data requirements for CCM documentation
- [ ] Document care management policies and procedures to satisfy NCQA or URAC accreditation standards

Phase 2 — Patient Identification and Enrollment
- [ ] Apply risk stratification algorithm (e.g., HCC scoring, claims-based predictive model) to attributed panel
- [ ] Conduct outreach and obtain documented patient consent for CCM enrollment per CMS requirements (one-time written or verbal consent, documented in the medical record)
- [ ] Complete baseline comprehensive assessment including clinical, functional, and social determinant domains

Phase 3 — Care Plan Development
- [ ] Develop individualized care plan with patient-identified goals
- [ ] Share care plan with all treating providers and the patient
- [ ] Document care plan in structured EHR fields accessible to the care team

Phase 4 — Active Management and Monitoring
- [ ] Conduct scheduled touchpoints per model protocol (minimum monthly for CCM billing eligibility)
- [ ] Track and document all care management time per CMS time-counting rules
- [ ] Coordinate referrals, transitions, and community services per the care plan
- [ ] Update care plan at defined intervals or following significant clinical events

Phase 5 — Evaluation and Quality Reporting
- [ ] Measure outcomes against HEDIS, CMS Star, or program-specific metrics
- [ ] Report quality measures per applicable payer contract requirements
- [ ] Conduct formal reassessment and determine continuation, step-down, or case closure

Reference table or matrix

References

• Centers for Medicare & Medicaid Services — Care Management
• CMS Physician Fee Schedule — Chronic Care Management
• Agency for Healthcare Research and Quality — Care Coordination
• Case Management Society of America — Standards of Practice
• NCQA — HEDIS Measures
• 42 CFR § 410.26 — Services incident to a physician's professional services
• 42 CFR § 438.208 — Medicaid Managed Care, Care Management Requirements
• CMS Innovation Center — Accountable Health Communities Model
• CDC — Chronic Disease Overview
• National Association of Social Workers — Case Management Standards
• [Patient-Centered Outcomes Research Institute (