Jackson-Hinds is the largest health center in Mississippi, and 44% of its Medicare patients are dually eligible, the patients Medicare's advanced primary care management codes pay the most for. It has carried two-sided accountable-care risk since 2020. Since 2025, Medicare pays a health center for the month of care between visits as its own codes, at national amounts, on top of every visit. This is the 24-month plan for that line, inside eClinicalWorks, with CoachCare staffing the enrollment and the monthly work.
Two counts, two jobs. 1,842 patients are in active remote care at month 24; the enrollment chart and the Scenario Explorer show 2,878 program enrollments, because a patient on both remote monitoring and a care-management program is one patient and two enrollments. $1,714,646 of the $4,018,082 is the health center's after CoachCare's fees.
Jackson-Hinds has served Jackson and Hinds County since 1970 and now reaches five counties through permanent clinics, a homeless clinic, mobile units and about twenty school-based sites. It reported 49,054 patients in 2025, more than any other health center in the state. For six years it has carried two-sided accountable-care risk on its Medicare panel. The work between visits is what that risk is scored on, and since 2025 Medicare pays a health center for that work as its own monthly line.
Jackson-Hinds reported 6,578 patients with Medicare as their primary coverage in 2025, and 2,869 of them are also enrolled in Medicaid. Dual eligibility sets the top advanced primary care management tier, so this panel earns more per patient-month than almost any other in remote care.
Jackson-Hinds has been part of the statewide health-center Medicare Shared Savings Program ACO since 2020, on the ENHANCED track, which carries downside risk as well as upside. Quality and total cost of care for its Original-Medicare patients are scored every year, and a documented monthly care line moves both.
Controlled blood pressure reached 63.1% in 2025, up from 49.0% in 2021, across 9,111 adults with hypertension. HRSA lists 2026 National Quality Leader recognitions in heart health, diabetes health and behavioral health. Continuous readings and a documented monthly touch keep that curve climbing.
eClinicalWorks runs at every site, the health center holds Patient-Centered Medical Home recognition, and it already employs case managers and community health workers and sends automated care-gap outreach. Most of what a remote-care line needs is already in place.
One structural fact completes the picture: Jackson-Hinds reports no remote patient monitoring to HRSA today (its telehealth is live video), and no chronic care management or advanced primary care management program appears on its site. 12,435 patients carry a hypertension diagnosis and 5,857 carry diabetes. They are seen a few times a year. The months between those visits are where the blood-pressure and diabetes measures move, where the ACO's cost line is decided, and where the 2025 codes pay.
Two rule changes made the between-visit month billable for a health center. The dual-eligible share of this panel makes it worth more here than almost anywhere else.
Care management used to bill as one bundled health-center code, G0511. Since 2025 a health center bills chronic care management, remote monitoring and advanced primary care management as individual codes at the national non-facility amounts, in addition to the PPS encounter for the visit. Each service is paid on its own, every month it is delivered. In Mississippi those national amounts sit above what a physician office is paid for the same codes. Every figure on this page is priced at the national amounts a health center is paid.
New 2026 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 patient home from one of the Jackson acute-care hospitals can now be followed through a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $314,931 of reimbursement over 24 months before denials and bad debt, about 7.8% of net reimbursement.
Advanced primary care management pays a flat monthly amount by tier: $16.37, $53.78, and $117.24 for a dual-eligible patient who is a Qualified Medicare Beneficiary. With 44% of the Medicare panel dually eligible, the tier mix here blends to $69.11 per patient-month. The enrollment and engagement labor that earns it is CoachCare's.
A named service line with its own P&L and scorecard, following the Medicare patients the health center already knows, inside the eClinicalWorks chart it 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 as the monthly payment for the longitudinal panel the accountable-care track already holds Jackson-Hinds responsible for.
| Service | Codes | CY2026, national non-facility | Use across the panel |
|---|---|---|---|
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $21.71 setup · $52.11/mo | Hypertension and diabetes cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $51.77 + $41.42 add'l · $26.05 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $66.13 + $50.44 add'l | Two or more chronic conditions; the longitudinal wrapper |
| Advanced primary care management | G0556 · G0557 · G0558 | $16.37 · $53.78 · $117.24/mo | The primary-care panel by complexity tier; the top tier is the dual-eligible tier |
| Transitional care management | 99495 · 99496 | Billed as a PPS visit | Discharges from the Jackson acute-care hospitals; not in the forecast below |
| Behavioral health integration | 99484 | $57.45/mo | The next arm; not in the forecast below |
Amounts are the CY2026 Medicare physician fee schedule national non-facility rates, the rail a health center bills the care-management codes on in addition to the PPS encounter, and the basis every figure on this page is priced on. Transitional care management is the exception: a health center bills it as a visit under the PPS.
A 24-month forecast for the RPM + CCM + APCM stack: the health center's own 6,578 Medicare patients, all of them in scope from month one, 27 physicians and nurse practitioners in adult primary care plus one CoachCare-funded enrollment specialist, the national amounts a health center is paid, and the eClinicalWorks integration. Transitional care, behavioral health integration and Mississippi Medicaid are not in these numbers; each is upside scoped below.
After denials and coinsurance bad debt; $1,181,393 in Year 1 and $2,836,688 in Year 2.
42.67% of net reimbursement after CoachCare's fees: 41.45% in Year 1, 43.18% in Year 2.
Unique patients in active remote care at month 24, up from 1,313 at month 12.
RPM 1,398 + CCM 789 + APCM 691 active enrollments at month 24.
| Program | Net reimb. | CoachCare fees | Net to health center |
|---|---|---|---|
| RPM | $1,692,837 | $966,950 | $725,887 |
| CCM | $1,437,804 | $732,736 | $705,068 |
| APCM | $887,441 | $506,144 | $381,296 |
| Implementation, eClinicalWorks integration, outreach | — | $97,605 | −$97,605 |
| 24-month total | $4,018,082 | $2,303,436 | $1,714,646 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the health center and never deducted from its margin. | |||
| Year | Net reimb. | CoachCare fees | Net to health center | Margin |
|---|---|---|---|---|
| Year 1 | $1,181,393 | $691,716 | $489,677 | 41.45% |
| Year 2 | $2,836,688 | $1,611,720 | $1,224,969 | 43.18% |
| 24 months | $4,018,082 | $2,303,436 | $1,714,646 | 42.67% |
Recurring care-management and monitoring volume over 24 months, filed by the health center's own billing team.
Blood pressure, weight and glucose: a continuous picture of the hypertension and diabetes cohorts between visits.
About $1,727,000 in acute-care cost that never gets spent, at $15,000 per admission.
About 25,774 care-team hours of monitoring, outreach and documentation carried by the service line, not by health-center staff.
APCM reaches its ceiling of 691 enrollments in month 8 and CCM its ceiling of 789 in month 15. Remote monitoring is the largest program and the slowest to fill: 1,398 of a 1,497 ceiling at month 24, 93% of the way there. On a panel this size the limit on remote monitoring is how fast patients can be enrolled, not how many are eligible, so enrollment capacity, from clinician referrals and the on-site specialist, is what moves the forecast. The first 90 days, modeled: 78 new enrollments in month 1, 130 in month 2, 181 in month 3.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 1,497 | 6,578 in scope × 65% eligible (4,276) × 35% acceptance | 93% by month 24 |
| CCM | 789 | 6,578 × 40% (2,631) × 30% | Month 15 |
| APCM | 691 | 6,578 × 35% (2,302) × 30% | Month 8 |
| At month 24 | 2,878 | Program enrollments = 1,842 patients | — |
Every figure above assumes one CoachCare-funded on-site enrollment specialist working across Jackson-Hinds' clinics. Without that specialist, 24-month net reimbursement falls to $3,203,087, $814,995 less. A second specialist lifts it to $4,582,578: $564,496 more reimbursement, $239,066 more net to the health center, and remote monitoring at its ceiling by month 20. Both specialists are CoachCare's payroll.
The roster is the second lever: on the full 45 adult-primary-care clinicians enrolled under the health center, including part-time and secondary-site clinicians, the same program is $4,816,963 of net reimbursement. The third is the Mississippi Medicaid remote-monitoring rail below. The fourth is the total cost of care the two-sided accountable-care track already scores, which every avoided admission moves.
Nearly a third of Jackson-Hinds' patients, 15,497 in 2025, are on Medicaid or CHIP. Mississippi Medicaid covers remote patient monitoring for chronic disease, prices the same setup, device and management codes the Medicare program uses, and since July 2021 no longer requires a patient to have been hospitalized before qualifying. That is a second population the program's devices and care team already know how to serve.
Mississippi Administrative Code Title 23, Part 225, Chapter 2 (remote patient monitoring; coverage rule effective July 1, 2021) and the Division of Medicaid fee schedule (rows effective July 1, 2025). Monitoring is ordered by a physician, physician assistant or nurse practitioner, prior-authorized through the state's utilization-management review, and delivered in the patient's home on an FDA Class II device. Mississippi Medicaid does not pay chronic care management, advanced primary care management, transitional care management or behavioral health integration; those are Medicare rails here.
Jackson-Hinds runs eClinicalWorks at every site, and this plan is priced on CoachCare's built-in eClinicalWorks integration, so clinicians enroll and monitor patients without learning a new system. It carries integrated ordering and enrollment by service and device, exchange of health history, integrated vital reports, compliance documentation and integrated care summaries, and automated claim generation. CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically through its billing engine, which removes the manual claim step for every patient, every month. An enrolled patient begins care in under five days.
A physician or nurse practitioner flags an eligible patient and places the order inside eClinicalWorks, by service and device, the way a lab order is placed. CoachCare picks it up, ships the device and reaches the patient.
Readings, calls and care-plan work happen on CoachCare's platform and care team, with the escalation pathway below routing anything that needs a clinician.
Every month, vitals, the Evidence of Care document, the care plan and the patient's enrollment status post to the eClinicalWorks chart. One chart, no second system for clinicians.
Claims are created automatically in the eClinicalWorks billing workflow with the care-management codes on them, and the health center's own billing team files them. No PDFs, no re-keying.
The health center's clinicians set the thresholds and own every clinical decision. CoachCare's care team works the readings and the calls between visits and routes each finding one of three ways. The thirty days after a discharge from one of the Jackson acute-care hospitals get a fixed three-touch cadence, because that is when readmissions happen.
Any hospitalization or observation stay in the last 60 days triggers three touches inside two weeks. It is also the TCM episode: contact within two business days, the visit within 7 or 14 days, and a device in the home before the first follow-up.
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, on any day. 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 health center designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a clean symptom check close 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 set cadence, the clinic is notified at every decision point, and a patient who stops transmitting is worked before a billing month is lost.
A remote care program built for a well-connected suburb would miss this panel. Jackson-Hinds serves five counties, from Jackson's neighborhoods to rural Utica, Edwards, Hazlehurst and Vicksburg and school sites in the Delta. Four in five patients with a known income live at or below the federal poverty line, and the health center runs a dedicated homeless clinic. Five design decisions follow from that.
Every cuff, scale and glucometer ships with its own cellular connection and transmits on its own. No smartphone, no home internet, no app to install, no account to set up. The device works the day it comes out of the box.
A visit can mean a long drive from Utica, Edwards or Hazlehurst. A documented monthly contact and a device already in the home reach patients between visits, alongside the mobile units Jackson-Hinds already runs.
Device instructions and call scripts are written plainly, at a low reading level, and matched to the chart. The program is designed for patients who are new to remote care and for caregivers who help them.
Lists come from the registries first: the dual-eligible Medicare panel for advanced primary care management, then the hypertension and diabetes cohorts for remote monitoring, then payer, so the Medicare and Mississippi Medicaid rails each get the patients who belong on them.
Most adult primary care here is delivered by nurse practitioners, and the care-management codes are built for general supervision. The case managers and community health workers already on staff become the program's local hands, with a billable monthly cadence behind them.
Jackson-Hinds serves Hinds, Warren, Copiah, Rankin and Sharkey-Issaquena counties from permanent clinics, mobile units and school sites. Hinds County Medicare is just over half Medicare Advantage and more than a quarter dually eligible, and the health center's own Medicare panel is more dual-eligible than the county.
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, repriced at the national amounts a health center is paid, the same basis the forecast itself uses.
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 $2,325,245 of the $4,018,082 in 24-month net reimbursement. Their own amounts move by a point or two through conversion-factor and RVU churn, so $36,721 of the $197,587 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 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 is moving remote care toward payment for results: per-member-per-month amounts with a share withheld and reconciled against outcomes. Fee-for-service code cuts and that shift are the same policy argument. A health center with a consented, documented, monthly-managed panel and continuous readings is what every version of that payment rewards, and this service line builds that panel under fee-for-service first.
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 orange can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at the national non-facility amounts on this forecast's own billing mix and APCM tier weights. Enrollment, acceptance and mix held constant. This is the rate change alone.
National non-facility amounts from the proposed rule's Addendum B. A health center bills the care-management codes on this rail, so the table and the repricing above sit on the same basis and reconcile to the dollar.
| 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 the year after.
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.
CoachCare operates as the service line's engine while the health center's physicians and nurse practitioners govern protocols and every clinical decision. Launch needs no new health-center headcount and no capital; the eClinicalWorks integration runs in parallel with onboarding, and the first enrollments follow the first orders.
eClinicalWorks integration scoped and started; a named program lead at the health center; P&L and scorecard; claim configuration with the billing team; protocol sign-off for the hypertension and diabetes pathways; the discharge trigger wired to the three-touch cadence.
APCM across the dual-eligible Medicare panel, CCM across the two-plus-condition panel and RPM for the hypertension and diabetes cohorts; CoachCare's on-site enrollment specialist working across the Jackson clinics; the post-discharge cadence live from day one.
APCM full by month 8, CCM by month 15; remote monitoring keeps enrolling. Monthly scorecard to the executive team, with blood-pressure control and diabetes control at the top of it, and the decision on a second enrollment specialist made on real enrollment data.
Carry remote monitoring toward its ceiling, re-run eligibility against the payer reconciliation, size and launch the Mississippi Medicaid remote-monitoring line from the registries, bring transitional care to every discharge, and add behavioral health integration as the next arm.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
10,000+ providers running remote care programs day to day.
1,000+ programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded; 4 million+ care actions enabled.