G0558 · APCM
QMB share · net of coinsurance write-off
- Patients
- 16
- Rate / mo
- $93.79
- Annual
- $18,310
Practice opportunity
Model the care-management opportunity before you commit to a pilot.
Use organization-level assumptions to estimate the incremental enrollment gap, gross reimbursement, and the operating cost of internal or contracted capacity. Then take the model into a readiness review and replace assumptions with your real workflow.
No patient information or sign-in
Planning estimate, not a payment guarantee
Practice opportunity calculator
Interactive planning tool
Practice opportunity calculator
Choose a payer path, then use organization-level inputs. Original Medicare uses a labeled CY 2026 planning baseline. Medicare Advantage and Medicaid stay blocked until you supply a named, written rate source.
Step 1
Choose the payer path
The product never substitutes Medicare rates for a plan, state, program, or MCO.
Original Medicare is modeled from the published CY 2026 national non-facility APCM baseline, with the QMB coinsurance write-off shown explicitly.
Original Medicare baseline
Illustrative incremental annual gross
$8,556 per month
Modeled only for the increase from 4% current enrollment to 25% target enrollment.
Illustrative year-one figure, assuming enrollment ramps in over the first 12 months: $51,337, reaching $102,673 at steady state.
- Low
- $82,139
- Base
- $102,673
- High
- $123,208
Low / high are an illustrative +/-20% planning band around the base case, not a statistical forecast.
Already net of $4,578 a year in QMB coinsurance you cannot bill. Allowed amounts would total $107,251; this model uses the lower figure as its realizable planning estimate.
- Modeled chronic-condition pool
- 670
- Incremental patient gap
- 194
67% chronic-condition share
12.5% QMB share
Uses practice-level assumptions only. No patient information is requested or needed.
Your provider organization
4 inputsTotal Medicare patients attributed to the organization, including QMB patients. Medicare Advantage members are carved out below.
%
%
Current share of eligible patients enrolled in care-management services.
%
The share your practice could support with an organized monthly-care workflow.
Planning estimate only—not a reimbursement forecast. Eligibility, documentation, billability, and rates require patient-level review by the practice.
Implementation decision
Choose how the program runs.
Compare the operating model—not just the gross reimbursement estimate. Staffing can be planned before a rate is known; net economics stay blocked until the payer rate is ready.
- Incremental gross annual
- $102,673
- Staffing expense (coordinator–RN)
- $110,000–$200,000/ yr
- Incremental contribution after modeled cost
- −$7,327
- Care-management capacity
- 2 modeled FTEs
FTE need is a planning estimate and may be met with existing or new staff. Actual capacity varies with acuity, workflows, supervision and program requirements.
This is not practice net income. No Kept Count platform fee is entered, so contribution is shown before any platform fee — enter your contracted rate above to net it out. It still excludes implementation pricing, supervision, RCM and denial effects, overhead, and any coinsurance shortfall beyond the modeled collection rate. For Medicare Advantage and Medicaid, payer, contract, state, program, and FQHC payment-methodology validation also belongs in the provider-specific implementation brief.
In either model, your provider organization retains clinical supervision, the EHR, coding, claims submission and final compliance authority. The contracted-capacity model still requires named practice owners for supervision, escalation and billing review; actual internal resource needs vary.
Assumptions and exclusions
FTE need is a planning estimate and may be met with existing or new staff. Actual capacity varies with acuity, workflow, supervision, and program requirements.
This is not practice net income. It excludes implementation, supervision, RCM and denial effects, overhead, patient cost sharing, payer variation, and uncollected amounts.
Your provider organization retains clinical supervision, the EHR, coding, claims submission, and final compliance authority.
Refine the modelStrategy, QMB share, realization, staffing, fee and code assumptions
Care model
APCM-first is the default because it organizes eligible care around monthly service requirements rather than a minutes-first workflow.
The model assigns G0556 to the non-chronic share, G0557 to the 2+ chronic non-QMB share, and G0558 to the QMB share, as planning assumptions. The practice must validate eligibility and tier selection.
%
CMS: QMB is roughly 1 in 8 Medicare beneficiaries nationally. Override with a regional figure — the model uses G0558 for this share as an assumption; eligibility and tier selection require practice review. QMB is not the same population as dual-eligible.
Realization assumptions
%
Share of the 20% non-QMB Part B coinsurance the practice actually collects. QMB coinsurance is never billable and is modeled separately above.
%
Modeled enrollment loss over a year. Reduces the average enrolled base the model prices, not just the year-end figure.
Staffing assumptions
Refine the capacity and cost assumptions behind the practice-team model.
Actual capacity depends on acuity, workflow design, supervision, staffing and program requirements.
Salary, benefits and practice overhead for a generic care coordinator or CHW. Editable assumption, not a wage survey.
Same role, staffed at RN level instead. Shown as the high end of the staffing-cost range below. Editable assumption, not a wage survey.
Enter your contracted platform fee to net it against contribution. Left blank (zero) by default — this calculator does not publish Kept Count's pricing. When entered, it is subtracted from contribution below, the same way the contracted-capacity fee already is.
Detailed model output
Published rates and internal planning assumptions are shown separately. Billing authority and final coding remain with the practice.
Illustrative incremental contribution after staffing
−$7,327/ year
G0557 · APCM
2+ chronic, non-QMB
- Patients
- 114
- Rate / mo
- $53.78
- Annual
- $72,023
G0556 · APCM
Base tier · 0–1 chronic conditions
- Patients
- 64
- Rate / mo
- $16.37
- Annual
- $12,340
- Incremental gross annual
- $102,673
- Care-team FTEs
- 2
- Staffing / yr
- $110,000
APCM inputs use CMS CY 2026 national non-facility rates: G0556 $16.37, G0557 $53.78 and G0558 $117.24 allowed. The QMB tier is modeled at $93.79 — QMBs cannot be billed Medicare cost sharing, so the 20% coinsurance is written off or crossed over to a state Medicaid program that many states pay at zero. Non-QMB coinsurance is further reduced by the modeled collection rate, and the enrolled base by modeled attrition. Medicare Advantage members are excluded from this fee-for- service math entirely. Actual payment, eligibility and cost sharing vary and must be validated. See the CMS Physician Fee Schedule — Advanced Primary Care Management. The optional CCM-first view uses an internal illustrative $78 planning blend—not a single CMS rate and not an assertion that services may be billed together. The model assumes 67% of the fee-for-service panel has 2+ chronic conditions (CMS chartbook estimate); the remainder is modeled at the G0556 base tier. The year-one ramp and low/base/high band are illustrative planning assumptions, not forecasts. QMB protections, service requirements, documentation and billing compatibility must be verified against current CMS and MAC guidance during Pre-Billing review.
A useful estimate ends with an operating plan.
We can map your actual panel, staffing, supervision, EHR and billing handoffs, then identify which assumptions need clinical, finance, compliance, or payer validation before launch.