What chronic conditions are listed in the CMS chronic condition List?

Editorial team Published on

The Centers for Medicare & Medicaid Services (CMS) maintains the Chronic Condition Data Warehouse (CCW) which tracks a standard set of chronic and mental health conditions (historically 21 core conditions, expanding up to 30+ condition algorithms), as well as a distinct list of 15 core clinical conditions used to determine patient eligibility for Chronic Condition Special Needs Plans (C-SNPs).

The 15 CMS-Approved Clinical Conditions for C-SNPs

To qualify for a Medicare C-SNP, a beneficiary must be diagnosed with at least one of these 15 medically complex, chronic, or disabling categories:

  • Chronic alcohol and other drug dependence
  • Certain autoimmune disorders (such as rheumatoid arthritis, systemic lupus erythematosus, or polymyalgia rheumatica)
  • Cancer (excluding pre-cancer conditions or minor skin cancers)
  • Certain cardiovascular disorders (such as cardiac arrhythmias, coronary artery disease, peripheral vascular disease, or valvular heart disease)
  • Chronic heart failure
  • Dementia (including Alzheimer's disease)
  • Diabetes mellitus
  • End-stage liver disease
  • End-stage renal disease (ESRD) requiring any mode of dialysis
  • Certain severe hematologic disorders (such as hemophilia)
  • HIV/AIDS
  • Certain chronic lung disorders (such as asthma, chronic obstructive pulmonary disease, or pulmonary fibrosis)
  • Certain chronic and disabling mental health conditions (such as bipolar disorders, major depressive disorders, paranoid disorder, schizophrenia, and schizoaffective disorder)
  • Certain neurologic disorders (such as amyotrophic lateral sclerosis/ALS, epilepsy, Huntington’s disease, multiple sclerosis, Parkinson’s disease, polyneuropathy, and spinal stenosis)
  • Stroke and stroke-related neurologic deficits

Standard CCW Research Conditions (Data Warehouse)

If you are looking at broad data tracking through the broader CMS Chronic Conditions Data Warehouse, CMS identifies cohorts using administrative claims flags for a wider baseline of common illnesses, which historically include:

  • Alzheimer’s disease / dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma and chronic obstructive pulmonary disease (COPD)
  • Atrial fibrillation and other heart rhythms
  • Cancer
  • Chronic kidney disease
  • Depression
  • Diabetes
  • Heart failure and ischemic heart disease
  • Hypertension and hyperlipidemia (high blood pressure and high cholesterol)
  • Osteoporosis
  • Stroke / transient ischemic attack (TIA)

What are the 26 chronic conditions?

The term "26 chronic conditions" typically refers to two distinct official healthcare frameworks: the CMS Chronic Condition Data Warehouse (CCW) used by Medicare in the United States, and the Chronic Disease List (CDL) utilized by South African medical schemes to mandate minimum coverage.

Because both standards track exactly 26 core conditions, they are outlined below.

1. The 26 Chronic Conditions (U.S. Medicare / CMS CCW)

The Centers for Medicare & Medicaid Services (CMS) uses a standardized set of 26 chronic conditions to study health outcomes and spending:

  1. Acquired Hypothyroidism
  2. Acute Myocardial Infarction (Heart Attack)
  3. Alzheimer's Disease
  4. Alzheimer's Disease and Related Dementias
  5. Anemia
  6. Asthma
  7. Atrial Fibrillation
  8. Benign Prostatic Hyperplasia (BPH)
  9. Cancer (Colorectal)
  10. Cancer (Endometrial)
  11. Cancer (Breast)
  12. Cancer (Lung)
  13. Cancer (Prostate)
  14. Cataract
  15. Chronic Kidney Disease (CKD)
  16. Chronic Obstructive Pulmonary Disease (COPD)
  17. Depression
  18. Diabetes
  19. Glaucoma
  20. Heart Failure
  21. Hip/Pelvic Fracture
  22. Hyperlipidemia (High Cholesterol)
  23. Hypertension (High Blood Pressure)
  24. Ischemic Heart Disease
  25. Osteoarthritis / Rheumatoid Arthritis
  26. Stroke / Transient Ischemic Attack (TIA)

2. The 26 Chronic Disease List (CDL) Conditions (South Africa)

If you are looking at medical insurance or aid frameworks, the Council for Medical Schemes mandates full coverage for the following 26 life-threatening chronic conditions:

  • Addison’s disease
  • Asthma
  • Bipolar mood disorder
  • Bronchiectasis
  • Cardiac dysrhythmias (Arrhythmias)
  • Cardiac failure (Heart failure)
  • Cardiomyopathy
  • Chronic obstructive pulmonary disease (COPD)
  • Chronic renal disease (Kidney disease)
  • Coronary artery disease
  • Crohn’s disease
  • Diabetes insipidus
  • Diabetes mellitus (Type 1 & Type 2)
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • Hyperlipidaemia (High cholesterol)
  • Hypertension (High blood pressure)
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson’s disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus (SLE)
  • Ulcerative colitis

What conditions are considered chronic by Medicare?

Medicare generally defines a chronic condition as a physical or mental health issue that lasts 12 months or longer, requires ongoing medical management, and places the person at risk of functional decline or hospitalization.

The Centers for Medicare & Medicaid Services (CMS) specifically highlights 15 core chronic clinical categories for its programs, and broader lists used for programs like Chronic Condition Special Needs Plans (C-SNPs) and Medicare Benefits Available for Chronic Conditions via AARP cover dozens of related diagnoses.

Core CMS Chronic Condition Categories

  • Diabetes mellitus
  • Chronic heart failure and specific cardiovascular disorders
  • Dementia and Alzheimer's disease
  • Stroke
  • Cancer (excluding pre-cancerous conditions)
  • Chronic lung disorders (such as COPD and emphysema)
  • End-stage renal disease (ESRD) requiring dialysis
  • End-stage liver disease
  • HIV/AIDS
  • Certain autoimmune disorders (such as rheumatoid arthritis or lupus)
  • Chronic alcohol and other drug dependence
  • Severe hematologic disorders
  • Chronic and disabling mental health conditions (such as depression, bipolar disorder, and schizophrenia)
  • Certain neurologic disorders (such as Multiple Sclerosis or Parkinson's disease)
  • Other specific severe/disabling conditions meeting complexity criteria

Common Additional Qualifying Conditions

Programs like Chronic Care Management (CCM) often include overlapping or co-occurring long-term problems if you have two or more concurrent conditions:

  • High blood pressure (Hypertension)
  • High cholesterol (Hyperlipidemia / Dyslipidemia)
  • Arthritis (osteoarthritis and rheumatoid)
  • Osteoporosis
  • Obesity
  • Asthma

How does CMS define chronic conditions?

The Centers for Medicare & Medicaid Services (CMS) defines a chronic condition as a physical or mental health problem that is expected to last at least 12 months (or until the patient's death) and places the patient at significant risk of death, acute worsening, or functional decline.

Key Criteria

  • Duration: Lasts or is expected to last for 12 months or longer.
  • Severity/Risk: Puts the person at risk for death, acute exacerbation (sudden worsening), or functional decline.
  • Multiple Conditions (MCC): CMS highlights Multiple Chronic Conditions when a patient has two or more concurrent chronic conditions that complicate each other and demand ongoing care coordination.

Qualifying Contexts

  • Chronic Care Management (CCM): CMS uses this framework to provide non-face-to-face support and separate billing codes for beneficiaries managing two or more qualifying long-term conditions.
  • Special Needs Plans (C-SNPs): For Medicare Advantage, CMS defines severe or disabling chronic conditions as co-morbid, medically complex issues that are life-threatening or substantially disabling and require specialized care systems. Rather than using a rigid, closed roster, CMS guidelines generally encompass any diagnosed disease meeting the duration and risk criteria, supported by analytical tracking through the Chronic Condition Data Warehouse (CCW).

What chronic conditions are listed on the CMS list?

The Centers for Medicare & Medicaid Services (CMS) officially defines 15 core clinical conditions that qualify beneficiaries for Chronic Condition Special Needs Plans (C-SNPs). CMS also tracks a broader set of conditions through its Chronic Condition Data Warehouse.

The 15 Official CMS C-SNP Conditions

CMS identifies these 15 groups as severe, life-threatening, or medically complex:

  • Alcohol and Drug Dependence: Chronic abuse of alcohol or other substances.
  • Autoimmune Disorders: Includes rheumatoid arthritis, systemic lupus, and polymyositis.
  • Cancer: Active cancers, excluding pre-cancerous or in-situ conditions.
  • Cardiovascular Disorders: Includes coronary artery disease, arrhythmias, and peripheral vascular disease.
  • Chronic Heart Failure: Long-term heart failure.
  • Dementia: Alzheimer's disease and related memory-loss conditions.
  • Diabetes Mellitus: Type 1 and Type 2 diabetes.
  • End-Stage Liver Disease: Advanced, irreversible liver damage.
  • End-Stage Renal Disease (ESRD): Kidney failure requiring dialysis.
  • Severe Hematologic Disorders: Includes sickle-cell disease, hemophilia, and aplastic anemia.
  • HIV/AIDS: Human immunodeficiency virus infection.
  • Chronic Lung Disorders: Includes asthma, chronic bronchitis, emphysema, and pulmonary fibrosis.
  • Disabling Mental Health Conditions: Includes schizophrenia, bipolar disorders, and major depression.
  • Neurologic Disorders: Includes Parkinson's disease, multiple sclerosis, epilepsy, and ALS.
  • Stroke: History of stroke or related brain-function deficits.

Broader Tracked Conditions

For general care programs like Chronic Care Management Services, CMS recognizes an expanded list of over 30 categories. This wider group adds common issues like hypertension (high blood pressure), hyperlipidemia (high cholesterol), osteoporosis, and arthritis.

What is a Chronic Condition?

9 related questions found

What are the big 5 chronic conditions?

The "Big 5" major chronic conditions most frequently referenced in public health and medical literature are cardiovascular disease, cancer, chronic respiratory disease, diabetes, and stroke.

The Big 5 Conditions

  • Cardiovascular Disease: Conditions affecting the heart and blood vessels, such as coronary artery disease and heart failure, representing a leading global cause of death.
  • Cancer: A broad group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body.
  • Chronic Respiratory Disease: Long-term conditions affecting the airways and lungs, most notably chronic obstructive pulmonary disease (COPD) and asthma.
  • Diabetes: A metabolic condition characterized by high blood sugar levels resulting from defects in insulin production, insulin action, or both.
  • Stroke: A cerebrovascular condition where poor blood flow to the brain results in cell death, frequently categorized alongside cardiovascular events.

(Note: In specific contexts like respiratory health, the "Big 5" can alternatively refer to major lung diseases: COPD, asthma, acute lower respiratory infections, tuberculosis, and lung cancer.)

What are the five things that Medicare will not cover in 2026?

Original Medicare (Parts A and B) does not cover routine dental care, routine vision care, hearing aids, long-term custodial care, and health care received overseas.

Major Uncovered Services in 2026

  • Most dental care: Original Medicare does not pay for routine cleanings, checkups, fillings, tooth extractions, root canals, or dentures.
  • Routine vision care: Regular eye exams, eyeglasses, and contact lenses are excluded, though treatments for medical eye conditions like cataracts or glaucoma are covered.
  • Hearing aids: Original Medicare does not cover hearing aids or routine exams used to fit them.
  • Long-term care: Extended nursing home care or custodial care (help with daily personal activities like bathing or dressing) is not covered outside of limited short-term skilled nursing rehabilitation.
  • Overseas coverage: Medical care received outside of the United States and its territories is generally excluded, with rare exceptions like emergencies on cruise ships close to a U.S. port.

What illnesses automatically qualify you for Medicare?

Two specific medical conditions automatically qualify individuals for Medicare under the age of 65: Amyotrophic Lateral Sclerosis (ALS) and End-Stage Renal Disease (ESRD).

Amyotrophic Lateral Sclerosis (ALS)

  • Also known as Lou Gehrig's disease.
  • Qualifies for Medicare the exact month that Social Security Disability Insurance (SSDI) benefits begin.
  • There is no 24-month waiting period.

End-Stage Renal Disease (ESRD)

  • Permanent kidney failure requiring regular dialysis or a kidney transplant.
  • Generally qualifies for Medicare starting three months after dialysis begins, or sooner if participating in home dialysis training.
  • Coverage can also begin the month a transplant is performed.

General Disability Qualification

  • Other severe illnesses or injuries do not automatically qualify on their own.
  • Individuals must receive Social Security Disability (SSDI) benefits for 24 consecutive months before Medicare coverage starts for other conditions.

What are the 11 major chronic illnesses?

Major chronic illnesses are long-lasting health conditions that generally last for one year or more and require ongoing medical attention or limit daily activities.

While health organizations like the Centers for Disease Control and Prevention (CDC) track broad categories of chronic diseases rather than a single official "top 11" list, medical studies and public health data frequently group the most prevalent and impactful major chronic conditions into the following 11 key types:

  • Hypertension (High Blood Pressure): A condition where the force of blood against artery walls is too high, raising the risk of heart disease and stroke.
  • Heart Disease: A broad term for conditions affecting heart function, including coronary artery disease and heart failure.
  • Type 2 Diabetes: A metabolic disorder where the body becomes resistant to or does not produce enough insulin, causing high blood sugar.
  • Cancer: A collection of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body.
  • Chronic Obstructive Pulmonary Disease (COPD): A chronic inflammatory lung disease—often including chronic bronchitis and emphysema—that obstructs airflow.
  • Asthma: A chronic respiratory condition that inflames and narrows the airways, causing wheezing and shortness of breath.
  • Arthritis: Joint inflammation that causes chronic pain, swelling, and stiffness (such as osteoarthritis and rheumatoid arthritis).
  • Chronic Kidney Disease (CKD): The gradual loss of kidney function over time, which reduces the body's ability to filter waste.
  • Alzheimer's Disease and Dementia: Progressive brain disorders that destroy memory, thinking skills, and the ability to carry out simple tasks.
  • Depression and Mood Disorders: Long-term mental health conditions causing persistent feelings of sadness and a loss of interest in daily life.
  • Obesity: A complex medical condition involving an excessive amount of body fat that acts as a primary risk factor for many other chronic diseases.

How long does a condition have to be to be considered chronic?

According to major health organizations like the Centers for Disease Control and Prevention, a condition is generally considered chronic if it lasts for one year or longer.

Key Timeframes

  • 1 Year (Major Health Agencies): The CDC and similar public health groups define chronic diseases as lasting 1 year or more while requiring ongoing medical care or limiting daily activities.
  • 3 to 6 Months (General Medicine): Some clinical dictionaries and research definitions apply the term "chronic" to symptoms or conditions lasting longer than 3 months (such as chronic pain), while others use a 6-month threshold.

Key Characteristics

  • Ongoing Care: Requires continuous medical attention, management, or lifestyle changes.
  • Slow Development: Usually builds up gradually over time rather than appearing suddenly like an acute infection.
  • Long-Term Impact: Often persists for a lifetime, though symptoms can frequently be managed or controlled.