New in 2025: Advanced Primary Care Management Services
In 2025, Medicare introduced Advanced Primary Care Management (APCM) services to help patients living with complex, chronic conditions manage their health and achieve their quality of life goals.
Bluestone APCM services include:
- Support between in-person visits: We work directly with patients as well as their living community, integrated care team, and other service providers like specialists, physical therapists, and home health agencies to coordinate care services. We do this easily and efficiently through our online communication tool — The Bridge — to answer questions or concerns between visits. A doctor, nurse practitioner, or physician assistant is available 24 hours a day, every day, to address urgent medical concerns.
- Dedicated healthcare team: We create a comprehensive care plan that outlines patients’ chronic medical conditions, plans to treat, and goals of care to help manage their health in a way that honors their wishes. Patients receive personal attention from a primary care provider assigned to oversee their care, as well as a care team that may include nurses, social workers, or medical assistants, in the comfort of their home.
- Complex Care Management: Enrolled patients will be assigned a Complex Care Manager who will collaborate with their care team (community living staff, rehab facilities, in-home service providers, etc.) in the case of an emergency room visit or hospital stay to support their needs through the transition. Bluestone’s Complex Care Managers are nurses or social workers and will advocate for the right care at the right time and help patients return home as soon as safely possible.
Current Bluestone patients can talk with their Bluestone doctor, nurse practitioner or physician assistant to enroll. Interested in bringing Bluestone to your community? Fill out this form.
Frequently Asked Questions:
Who is eligible for APCM services?
APCM services are available to all Medicare beneficiaries who have one or more chronic conditions.
How is this different from the care I already receive? Why would I want APCM services?
Bluestone has always provided comprehensive care for our patients because we know this is the best type of care to manage complex, chronic conditions and avoid unwanted hospital stays. Enrolling in APCM means Medicare will now reimburse Bluestone for the care we provide in between visits. Examples of this work include communicating with community nursing staff and family about medical concerns, refilling medications, completing prior authorizations and medication paperwork, coordinating your care with hospital staff, reviewing records from specialists to maintain consistent treatment plans, reviewing test results and ensuring prompt treatment, and working for smooth transitions from the hospital or rehab center.
Medicare developed APCM to support clinics like Bluestone by providing reimbursement for the resources and management that Medicare recognizes are required to adequately care for patients with chronic, complex conditions. With APCM, in addition to the wraparound care we already provide, it provides access to a care manager to support you during ER, hospital, or skilled nursing stays and transitions.
Is there a copay? How are services billed?
Medicare pays for APCM services — cost-sharing may apply. Cost-sharing can come in the form of a co-pay or deductible. In the case of a co-pay, it is the same as Bluestone Primary Care services. For example, if a patient has 20% cost sharing/copay for primary care visits, it will be the same for APCM. The average copay is $0-10. If you have Medicare and Medicaid, there is no cost to you. Patients may contact their insurance provider for detailed information. A monthly charge is submitted to insurance for reimbursement according to CMS guidelines.
How do I enroll?
Medicare requires the doctor, nurse practitioner, or physician assistant who is submitting an APCM payment claim to share the following information with you or your healthcare power of attorney:
- You may only be enrolled under one doctor, nurse practitioner, or physician assistant at a time.
- You can stop APCM services at any time.
- Your Medicare, Medicaid, or Medicare Advantage plan will pay for APCM services, but cost-sharing may apply.
After you provide a simple verbal or written “yes” we will enroll you into APCM services.