The clinic already makes the monthly call. What it cannot see is the other 29 days. Since January, Medicare pays a Rural Health Clinic for that month, code by code, on top of the visit, and nine in ten of this county's beneficiaries are paid on exactly that fee schedule. This is the 24-month plan to bill for it, with CoachCare staffing the program inside Oracle Health.
Two counts, two jobs. The headline is 324 unique patients at month 24; the enrollment chart and the Scenario Explorer show 498 active program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments.
A county-owned hospital that kept a 25-bed Critical Access Hospital, a 24/7 emergency department where no patient left without being seen, surgery, cardiac rehab and an outpatient specialty clinic that brings cardiology, nephrology, surgery and orthopedics to town, in a county of 4,813 people. It runs a certified Rural Health Clinic, started a diabetes education program in 2024, recruited a new nurse practitioner to the clinic in August 2026, and has posted top-quartile rural quality performance two years running. An organization that already runs the discharge and already makes the monthly call is the right one to run the month in between.
Phillips County Medical Clinic bills on the hospital's own cost report and carries a Rural Health Clinic shortage designation. That is the rail the CY2026 care-management codes ride on: each code paid individually, on the RHC claim, on top of the visit.
213 discharges a year, 156 of them Medicare. Every one of those discharges is a hand-off the hospital schedules itself, and every discharge home is a transitional-care episode with the clinic on the other end.
A 24/7 emergency department with a 116-minute median visit and a 0% left-without-being-seen rate. Each of those visits by a clinic patient is a signal the care team can act on the same week rather than a chart note found at the next appointment.
The hospital and the clinic run on Oracle Health (Cerner), with the hospital's own billing team filing the RHC claims. CoachCare integrates into that chart, so referral orders, vitals, documentation and billing-ready claims stay in one place.
None of this is replaced. The care coordinator becomes the clinical lead of a larger program instead of its bottleneck, and the monthly call becomes one touch inside a month of data.
One structural fact completes the picture: no remote patient monitoring program is visible at meaningful scale in CY2024 Medicare claims or in the hospital's public materials. Since January, the RHC bills every care-management and monitoring code individually. The program that fills the other 29 days is also the program that captures that billing.
The clinic serves a county where one resident in four is 65 or older, the median age is 45.7, and the regional referral hospitals are more than 60 miles away in every direction. The visiting cardiology and nephrology clinics come to Phillipsburg on a schedule. The month between those visits is where the data has to live, and monitoring is how a rural clinic reaches a patient it sees in person a few times a year.
Three things changed at once for a Rural Health Clinic in 2026: how care management is billed, what remote monitoring can bill for, and where the state's rural health money is going.
Through September 2025, an RHC billed care management as one bundled code. From January 2026, RHCs bill chronic care management, remote monitoring and advanced primary care management as individual codes at national non-facility amounts, in addition to the all-inclusive rate for the visit. The program the clinic already runs is now paid service by service.
New CPT codes for 2 to 15 days of device data and for the first 10 minutes of management remove the 16-day floor that used to block episodic monitoring. A hospital discharge or an emergency visit can now be followed by a billable two-week monitoring window, next to the standard monthly stack. On this forecast the two new codes carry $78,092, about 9.4% of 24-month net reimbursement.
CMS awarded Kansas $221,898,008 for Year 1 of the Rural Health Transformation Program on December 29, 2025. The state's plan funds a statewide remote-monitoring program for rural hospital patients and recently discharged rural residents, expands centralized chronic-care-management and remote-monitoring support for rural clinics, and names Critical Access Hospitals and Rural Health Clinics as the target base. No award or participation is asserted here.
A named service line with its own P&L and scorecard, following the Medicare patients the clinic already knows, inside the Oracle Health chart the hospital already runs. Remote monitoring for the conditions that produce readings, chronic care management for patients with two or more conditions, and advanced primary care management where the monthly bundled code is the better fit.
| Service | Codes | CY2026, Kansas locality | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $19.36 setup · $46.97/mo | Hypertension, heart-failure and diabetes cohorts; 99445 opens 2–15-day windows after a discharge or an ED visit |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $48.22 + $38.86 add'l · $24.28 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $62.06 + $47.17 add'l | Two or more chronic conditions; the program the clinic runs today |
| Advanced primary care management | G0556 · G0557 · G0558 | $15.33 · $50.41 · $109.73/mo | The primary-care panel by complexity tier; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | $205.36 / $278.88 per discharge | Every inpatient discharge; not in the forecast below |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 67661 (WPS, Kansas statewide locality), the basis the Value Analysis below is priced on. Rural Health Clinics bill the care-management codes at national non-facility amounts, which run above the Kansas locality on every code in this table. Kansas Medicaid coverage of these code families is not modelled; Medicare is the only rail in every figure on this page.
A Critical Access Hospital is outside the federal readmission penalty programs, so this is not a penalty argument. It is a transfer argument. A patient who decompensates at home in Phillips County goes to the emergency department, and from there is often transferred more than 60 miles out of the county. The program's job is to catch the decompensation a week earlier, by phone and by reading, and route it to the clinic.
Any emergency visit or hospitalization in the last 60 days triggers three touches inside two weeks. For a hospital that owns the inpatient beds and the emergency department, the trigger fires the day the patient leaves, and when the patient was admitted it is also the TCM episode: contact within two business days, the visit within 7 or 14 days.
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 clinic.
Close the episode or extend it; anything trending is escalated through the engine below.
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 clinic 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 clinic's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule, the clinic is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
A 24-month forecast for the RPM + CCM + APCM stack: a 1,100-patient Medicare panel at the Rural Health Clinic, all of it in scope for Year 1, 6 referring clinicians plus CoachCare's enrollment outreach, Kansas locality rates for ZIP 67661, and the Oracle Health integration. Transitional care and the national RHC rate rail are not in these numbers.
| Program | Net reimb. | CoachCare fees | Net to hospital |
|---|---|---|---|
| RPM | $425,273 | $242,906 | $182,367 |
| CCM | $284,960 | $142,236 | $142,724 |
| APCM | $117,641 | $64,269 | $53,372 |
| Implementation, Oracle Health integration, outreach | — | $28,699 | −$28,699 |
| 24-month total | $827,874 | $478,110 | $349,764 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the hospital and never deducted from its margin. | |||
24-month margin: 42.25% of net reimbursement (Year 1 40.76%, Year 2 43.25%).
Year 1 is $135,669 net to the hospital on $332,852 of net reimbursement; Year 2 is $214,095 on $495,022. Month 1 is −$5,697 as the one-time setup lands ahead of the ramp; monthly net is positive from month 2 onward.
Recurring care-management and monitoring volume over 24 months, filed on the RHC claim by the hospital's own billing team.
Blood pressure, weight and glucose, a continuous picture of the hypertension, heart-failure and diabetes cohorts between visits.
About $473K in acute-care cost that never gets spent, at $15,000 per admission, and that many transfers that stay in the county.
About 6,218 care-team hours of monitoring, outreach and documentation carried by the service line, not by hospital staff.
APCM reaches its ceiling of 116 enrollments in month 4, CCM its ceiling of 132 in month 7, and RPM its ceiling of 250 in month 10. From there the census holds at 498 active enrollments, 324 unique patients. The binding constraint on this forecast is the size of the Medicare panel, not enrollment capacity. That is what the clinic's own chart counts, the new nurse practitioner's first full year and a confirmed list of which clinicians hold panels on the RHC claim all move.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 250 | 1,100 in scope × 65% eligible × 35% acceptance | Month 10 |
| CCM | 132 | 1,100 × 40% × 30% | Month 7 |
| APCM | 116 | 1,100 × 35% × 30% | Month 4 |
| At month 24 | 498 | Active program enrollments = 324 unique patients | — |
Every ceiling above is reached with one CoachCare-funded on-site enrollment specialist working the clinic. Without that specialist the same ceilings are reached months later and remote monitoring never fills inside the forecast; the 24-month net reimbursement falls to $570,035. The specialist cannot raise a ceiling, but reaching it in month 10 instead of never is worth $257,839 over 24 months, and it is CoachCare's payroll.
A Rural Health Clinic bills the care-management codes at national non-facility amounts on the RHC claim. The forecast on this page uses the Kansas locality amounts, which sit below national on every code in the basket. Priced at the national amounts with the same census, 24-month net reimbursement is $890,489, and because CoachCare's fees are per active patient per month, the whole difference, $62,615, is the hospital's.
The hospital and the clinic run on Oracle Health (Cerner). CoachCare connects to it through an HL7 and FHIR integration: eligibility flags and referral orders leave the chart; monitored vitals, care documentation, enrollment status and billing-ready claims come back into it. The hospital's own billing team files the RHC claims it already files. The integration runs in parallel with onboarding, so it does not gate the first enrollments.
the integration is built alongside onboarding, training and care-team assignment; the first enrollments do not wait for it.
a physician, NP or PA flags an eligible patient and submits the referral from inside Oracle Health; CoachCare picks it up, ships the device and reaches the patient.
claims arrive billing-ready in the workflow the hospital's own billing team already runs for the RHC claim. No PDFs, no re-keying.
Kansas received $221,898,008 for the first year of the Rural Health Transformation Program on December 29, 2025. The state's plan, filed by the Kansas Department of Health and Environment, funds a statewide remote-monitoring program for rural hospital patients and recently discharged rural residents, expands centralized chronic-care-management and remote-monitoring support for rural clinics, and names Critical Access Hospitals and Rural Health Clinics as the target base. No award or participation is asserted on this page.
A consented longitudinal panel. Documented monthly care management. Continuous physiologic data. A working readmission-prevention loop. Whatever the state's rural health plan offers a Critical Access Hospital and its clinic next, that is the readiness it will be measured on, and it is what this service line builds under fee-for-service first, while every month of it is paid. A clinic with its own program running plugs into a state program on its own terms.
Kansas Medicaid coverage of the remote-monitoring and chronic-care code families is not confirmed, so the forecast on this page is Medicare only. Duals are 7.6% of the county's beneficiaries, and they are inside the Medicare figures already; no Medicaid dollar sits in any figure above.
CoachCare operates as the service line's engine while the clinic's physicians and advanced practitioners govern protocols and every clinical decision. Full-service delivery means launch needs no new hospital headcount; the Oracle Health integration runs in parallel with onboarding, and the first enrollments follow the first referral orders.
Oracle Health integration scoped and started; named program lead at the hospital; P&L and scorecard; RHC claim configuration with the billing team; the existing chronic care management enrollees reconciled into the program; protocol sign-off for the hypertension, diabetes, heart-failure and COPD pathways; the inpatient and emergency discharge trigger wired to the three-touch cadence.
APCM and CCM across the two-plus-condition panel and RPM for the hypertension and heart-failure cohorts; CoachCare's on-site enrollment specialist working the clinic; the post-discharge cadence live with the first enrollment.
APCM fills in month 4, CCM in month 7, RPM in month 10; monthly scorecard to the executive team and the Board of Trustees.
Re-validate eligibility against chart data, bring the new nurse practitioner's full first year into the panel, add transitional care at every hospital discharge, and align the program's reporting with whatever the state's rural health plan offers next.
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 hospital's own Kansas locality amounts rather than 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 carry $402,601 of the $827,874 in 24-month net reimbursement. Their own amounts move by a point or two, so $6,861 of the $47,385 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 hospital 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. A rural clinic with a consented panel and a year of physiologic data behind it is already on that road.
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 red can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at WPS Kansas statewide locality amounts, non-facility, on this forecast'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 Kansas 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.
The comment period on CMS-1848-P closed 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 fits Phillips County Health Systems specifically, not remote care in general.
Individual care-management codes on the RHC claim, in addition to the all-inclusive rate, filed by the hospital's own billing team. The 2026 change from the bundled code is the reason the forecast on this page exists, and the program is built around it.
Enrollment outreach, care managers at about 160 patients each, device logistics, 24/7 alert triage and billing preparation are CoachCare's payroll. The 3.0 FTE-years of work in the forecast never touch the hospital's staffing plan, and the care coordinator the clinic already has leads the clinical side of it.
Every inpatient discharge of an enrolled patient fires the three-touch cadence the same day, every ED visit is a trigger, and critical readings escalate through one engine whose urgent policy supersedes any preference. A hospital that owns the inpatient beds, the emergency department and the clinic is the ideal shape for this program.
An HL7 and FHIR integration carries referral orders out and vitals, documentation, enrollment status and billing-ready claims back in. One chart for clinicians, one workflow for the billing team, no second system.
Every device ships with its own cellular connection, so the program does not depend on home broadband or a smartphone app. Patient materials are written at a low reading level for a rural Medicare population, and every patient has a named care manager who calls.
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.