Advanced Primary Care Management: What to Know About CMS’s New Program

Updated on January 25, 2025

The landscape of primary care has been very slowly shifting from fee-for-service (FFS) and toward population- and value-based care models, driven in large part by ongoing efforts from the Centers for Medicare & Medicaid Services (CMS) to meet their goal of having 100% of traditional Medicare patients in some sort of value-based care model by 2030. The newest and most unorthodox initiative that the federal agency seems to hope will accelerate this migration is advanced primary care management (APCM), a program included in the 2025 physician fee schedule (PFS) final rule that CMS is covering starting this year. 

APCM represents a hybrid approach that essentially blends FFS with population health payment model principles. CMS has piloted similar models over recent years through opt-in, alternative payment models like Primary Care First and Comprehensive Primary Care Plus (CPC+). APCM represents CMS’s efforts to introduce non-FFS elements into the traditional FFS program in hopes of convincing practices heavily invested in the FFS structure to accept CMS’s plan for value-based care and population health payments. While APCM is in its infancy, considering the concept was first introduced in the 2025 PFS proposed rule, CMS is throwing its weight — and money — behind the new program in hopes of motivating primary care practices and federally qualified health centers (FQHCs) to implement the new program. 

Further Understanding the Vision Behind APCM

APCM is a reimagined framework for delivering primary care that includes a new set of HCPCS billing codes. In this way, APCM is both a new service and also a mini-payment model nested within FFS. At its core, APCM is designed to achieve “whole-person care” through a team-based, technology-supported approach that also prioritizes accessibility and equitable care​​. Despite numerous pilot programs and models over the past decade, like capitation, bundling, and shared savings, we have yet to see widespread adoption of value-based care principles in primary care — which one could argue is problematic given CMS’s aforementioned goal of all Medicare beneficiaries having some form of accountable care arrangement by 2030​.

APCM reflects what appears to be a strategic pivot by the federal agency, one in which it targets the less controversial aspects of care management while maintaining the flexibility and familiarity of the existing FFS system. APCM is both a continuation and an evolution of a program like chronic care management (CCM). CMS wants to see more longer-term, patient-centered care relationships that promote better chronic health outcomes, especially for those with chronic conditions that would benefit from ongoing management. APCM also aligns with CMS’s broader goal of achieving reductions in hospitalizations and emergency department visits through better proactive, preventive, and coordinated care. 

APCM Requirements

To bill for APCM, providers must complete a set of requirements that CMS has broken down into 13 elements touching on care delivery, technology, and population health management. Not all these elements — or services — must be provided every month. Rather, all must be available, and only those elements considered “clinically appropriate” for an individual patient must be delivered. Noteworthy elements include the following:

  • Providers must conduct an initiating visit — which can be done virtually — and obtain patient consent to participate in the APCM program. 
  • Patients must have around-the-clock (24/7) access to a member of their care team to address urgent needs.
  • Patients must designate a care team member to manage routine appointments and coordinate any necessary care transitions.
  • Providers must develop, maintain, and share with patients care plans that address specific patient health needs, goals, and preferences. 
  • Practices must use technology to identify care gaps and stratify patients based on clinical risk. 
  • Practices must offer secure messaging, portals, or other non-phone communication methods to patients. 
  • Practices must assess care quality, total cost of care, and performance metrics using certified EHR technology.

How APCM Differs From Other Care Management Programs

APCM marks a significant departure from past care management programs in a few noteworthy ways. For example, unlike CCM, which requires a minimum of 20 minutes of clinical staff time per month to bill, APCM allows providers to bill for patients who meet a set of defined service requirements regardless of how much time is spent delivering services. This change shifts the focus from tracking and documenting time (i.e., time-based metrics) to the availability of services and infrastructure that meet patient needs and can help improve outcomes while reducing care costs​​.

APCM offers three reimbursement levels based on patient care complexity. For APCM provided to low-complexity patients — those with zero chronic conditions or a single chronic condition — CMS pays $15 per month. APCM provided to moderate-complexity patients — those with multiple chronic conditions — CMS pays $50 per month. APCM for high-complexity patients — those who are qualified Medicare beneficiaries (QMB) with multiple chronic conditions — CMS pays $110 per month​. CMS has estimated that more than one out of eight Medicare beneficiaries are in the QMB program.

APCM bundles transitional care, virtual check-ins, and remote monitoring into this single billing structure. It is important to note that APCM does not bundle remote patient monitoring (RPM). RPM is a strong complement to APCM and additional service to provide to APCM patients as it allows for the continuous tracking of patient health metrics. Integrating RPM with APCM further supports data-driven care and creates additional revenue opportunities.

Seizing the APCM Opportunity 

For practices and FQHCs, launching an APCM program can be a great way to further support patients while adding revenue at a time when reimbursement is under pressure. It is understood that primary care providers are often spending significant amount of time on activities included in APCM like chronic disease management, care coordination, and remote monitoring, but this is work that typically goes unreimbursed in the current system because a specific time threshold is not met. APCM seeks to help reverse this problematic trend.

Before adding APCM, organizations should assess their patient population to determine who is eligible and within what tier (i.e., complexity) and analyze existing workflows to determine how APCM can enhance a care management program or possibly replace services like CCM for select patients. This may require consolidating services to reduce administrative burdens, improve billing efficiency, and avoid problematic duplication and billing of services.

APCM’s success hinges significantly on an organization’s technology infrastructure and the ability for electronic solutions to help meet the program’s various requirements and do so efficiently and with appropriate documentation. Providers should assess whether they already have solutions that can support APCM and work to fill any gaps.

As with any new program, prioritization of patient education and engagement will be crucial. Providers will need to communicate the benefits of APCM, services included in the program, and patient financial responsibility. Similarly, staff training and education are crucial, particularly concerning the various documentation and access requirements identified in APCM’s 13 elements.

APCM represents an exciting new way for providers to improve patient outcomes and secure sustainable revenue streams — revenue that could be significantly enhanced through pairing the service with RPM. For many organizations, adding APCM may be a relatively low lift, depending on existing workflows and technology. 

It’s clear that CMS has high hopes for APCM as a mechanism to drive more care toward population health and value-based models — one that emphasizes whole-person, team-based care that is proactive, sustained, and prioritizes quality over volume. Organizations would be wise to determine whether APCM can address unmet patient needs and do so in a way that helps strengthen provider financial viability at a time when reimbursement remains under significant pressure. 

Daniel Tashnek
Daniel Tashnek
Co-Founder at 

Daniel Tashnek is the co-founder of Prevounce Health, a healthcare software and services company that simplifies the provision of preventive medical services, chronic care management and remote patient management. Daniel is also a practicing healthcare attorney specializing in regulatory compliance, reimbursement, scope of practice, and patient care issues.