Medicare doesn’t assign you a personal case manager the way private insurance sometimes does, but several pathways exist to get dedicated help coordinating your care. The route that works best depends on whether you have Original Medicare or a Medicare Advantage plan, how many chronic conditions you manage, and whether you’re currently in a hospital or living in a care facility.
Chronic Care Management Through Your Doctor
The most direct way to get ongoing care coordination under Medicare is through the Chronic Care Management (CCM) program. If you have two or more serious chronic conditions expected to last at least a year, such as diabetes and arthritis, or heart failure and depression, Medicare Part B will pay for a health care provider to help manage your care across those conditions.
In practice, this means a nurse, care coordinator, or other staff member at your doctor’s office creates a comprehensive care plan, tracks your medications and specialist visits, follows up with you between appointments (often by phone), and helps prevent gaps in your treatment. To start, ask your primary care doctor whether their practice offers chronic care management services. Not every practice participates, so you may need to look for one that does.
CCM services are covered under Part B. After you meet the annual Part B deductible ($283 in 2026), you typically pay 20% of the Medicare-approved amount for these services. You’ll need to give written consent before your doctor’s office enrolls you, and you can only have one provider billing for CCM at a time.
Care Coordination in Medicare Advantage Plans
If you’re enrolled in a Medicare Advantage plan (Part C), your plan is often a better starting point than Original Medicare for getting a case manager. Most Medicare Advantage plans have care coordination built into their structure, and many assign case managers to members who have complex health needs, frequent hospitalizations, or multiple chronic conditions.
Call the member services number on your plan’s card and ask to be connected with their care management or care coordination team. Some plans will proactively reach out to you if claims data suggests you could benefit, but you don’t have to wait for that. You can request it yourself, especially after a hospitalization, a new diagnosis, or when you’re struggling to manage multiple providers and medications.
Special Needs Plans for Higher-Level Support
Medicare Special Needs Plans (SNPs) are a category of Medicare Advantage designed specifically for people who need intensive care coordination. Every SNP is required to provide care coordination services and tailors its benefits, provider networks, and drug coverage to the specific group it serves. There are three types:
- D-SNPs (Dual Eligible) serve people who qualify for both Medicare and Medicaid. These plans coordinate benefits between both programs, which can be especially valuable since navigating two systems simultaneously is notoriously confusing.
- C-SNPs (Chronic Condition) limit membership to people with specific chronic diseases or groups of related conditions. If you have a qualifying condition like diabetes, heart failure, or chronic lung disease, a C-SNP builds its entire care model around that condition.
- I-SNPs (Institutional) serve people who live in nursing facilities or other institutional settings. If you’re considering one, verify that the plan has providers who serve people at your specific facility.
You can search for available SNPs in your area on Medicare.gov during open enrollment or, for D-SNPs, during special enrollment periods that may apply throughout the year.
Hospital Discharge Planning
If you or a family member is currently in the hospital, federal law requires hospitals to provide discharge planning that includes a case manager or social worker. Hospitals must identify patients early in their stay who are likely to face health problems after discharge without proper planning, then develop a discharge plan supervised by a registered nurse, social worker, or other qualified professional.
This isn’t optional on the hospital’s part. The discharge planning process must treat you and your caregivers as active partners, focus on your goals and preferences, and help you select post-acute care providers like home health agencies, skilled nursing facilities, or rehabilitation centers. The hospital is also required to share quality data on these providers so you can make an informed choice. If discharge planning hasn’t been discussed with you, ask your nurse to connect you with the hospital’s case management or social work department. You, your representative, or your physician can request a discharge planning evaluation at any time during your stay.
Free Help From SHIP Counselors
If you’re not sure which path fits your situation, the State Health Insurance Assistance Program (SHIP) offers free, one-on-one counseling to Medicare beneficiaries. SHIP counselors are trained and certified to help with all parts of Medicare, including Original Medicare, Medicare Advantage, prescription drug plans, and Medigap policies. They can also help you apply for programs that reduce your costs, such as Medicaid, Medicare Savings Programs, and the Extra Help low-income subsidy.
SHIP operates through community-based networks of counselors who work in-person and by phone. They won’t act as your ongoing case manager, but they can help you figure out which type of care coordination you qualify for and how to access it. To find your local SHIP office, call 1-877-839-2675 or visit the shiphelp.org website.
How to Start the Process
The single most effective first step is calling your primary care doctor’s office and asking whether they provide chronic care management or can refer you to a care coordination program. If you have a Medicare Advantage plan, call member services and ask for their care management team directly. For people juggling multiple conditions, frequent hospital visits, or complex medication regimens, being persistent about this request matters. Many beneficiaries qualify for care coordination but never receive it simply because no one initiated the conversation.
If your current doctor’s practice doesn’t offer these services, you have the right to switch to a provider who does. Your local SHIP counselor can help you navigate that transition and make sure you’re enrolled in the Medicare plan structure that gives you the most support for your specific health situation.