Steady care, peace of mind every day
The Chronic Care Management (CCM) program gives you monthly health monitoring from a Vietnamese-speaking care team.
What is chronic care management?
Living with a chronic condition is more than taking pills every day. It means tracking your blood pressure, remembering check-up dates, worrying when lab results change, and wondering “is it okay to take all these medications at once?”
Chronic Care Management is a service that gives you a team by your side — a doctor, a pharmacist and a care coordinator. All speak Vietnamese and work together to care for you every month:
- The doctor sets and adjusts a care plan that fits your health.
- The pharmacist tracks and manages all of your prescriptions, checking for interactions when needed.
- The care coordinator calls every month: checking your blood pressure, blood sugar and any new symptoms; reviewing the medications you take; and reminding you of upcoming appointments.
You stay home and simply take the call. No clinic visit, no app to install.
Who is it for?
You may be a good fit if:
- You are 65 or older
- You have Medicare Original Part B (the red-and-blue card)
- You have 2 or more chronic conditions
- Your condition is expected to last 12 months or more, or for the rest of your life
- You are at risk of worsening health, hospitalization or decline without regular monitoring
Not sure if you qualify? Call 855-999-9911 and our team will help you check.
Three simple steps
Sign up
Call the hotline or fill out the sign-up form. The AgeWell team checks your insurance and eligibility. Then our doctor holds a first visit with you to set up your care plan.
Get a monthly call
Every month, a Vietnamese-speaking care coordinator calls you for at least 20 minutes — checking on your health, reviewing your medications, tracking your numbers, and answering all of your questions. All by phone, from home.
Peace of mind all month
You just follow the care plan and the coordinator’s reminders. The team keeps track of everything: medications on time, appointments as scheduled, labs on time. If anything is off, the doctor is notified right away. Need urgent help? Call us 24/7.
Concrete benefits
For you
- A Vietnamese-speaking team by your side: the coordinator calls every month, with the doctor and pharmacist joining when needed. You are never alone with your illness.
- Early detection of changes such as rising blood pressure, fluctuating blood sugar or new symptoms — before a hospital visit.
- No need to remember appointment and lab dates yourself. The team reminds you.
- A pharmacist reviews every medication you take to avoid dangerous interactions.
- When you need to see a doctor urgently, the team connects you right away. No calling around.
- Costs are covered by Medicare Original Part B, according to your plan’s benefits.
For your family
- Peace of mind knowing a professional team monitors your parents’ or grandparents’ health every month.
- No taking time off work for routine visits.
- Clear updates in Vietnamese about your loved one’s health.
- A team to call when you notice something unusual and don’t know who to ask.
Cost
Chronic Care Management is covered by Medicare Original Part B according to your plan’s benefits. Some Medicare plans may require a copay depending on the specific benefits.
We will check and clearly inform you before providing any service. No surprise costs.
Not sure how much your insurance covers?
Frequently asked questions
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