Alert
Medicare ACCESS Model to Align Chronic Care Payments with Patient Outcomes
The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model is a voluntary payment model that aims to transform chronic care delivery by aligning payments with patient health outcomes rather than service volume.
Designed to expand access to technology-supported care services for Medicare beneficiaries with chronic conditions, ACCESS is set to begin July 1, 2026, and run for 10 years. The first round of applications is due April 1, 2026.
Background and Rationale for the Medicare ACCESS Model
Chronic conditions—including hypertension, diabetes, chronic musculoskeletal pain, depression, and anxiety—affect more than two-thirds of Original Medicare beneficiaries. While digital health technologies such as telehealth, wearable devices, and health coaching apps have revolutionized chronic disease management, Medicare’s traditional fee-for-service (FFS) payment system provides limited coverage for these innovative services.
ACCESS addresses this gap by testing Outcome-Aligned Payments (OAPs), a recurring payment mechanism rewarding care providers for achieving measurable improvements in patients’ health. The Centers for Medicare & Medicaid Services (CMS) believe that an outcome-focused approach will provide clinicians with greater flexibility to deliver personalized, technology-enabled care that complements traditional in-person services.
Model Design and Participation Requirements
ACCESS invites participating care organizations to offer integrated, technology-supported chronic care management across four clinical tracks.
- Early Cardio-Kidney-Metabolic (eCKM): Hypertension, dyslipidemia, obesity with central markers, prediabetes
- Cardio-Kidney-Metabolic (CKM): Diabetes, chronic kidney disease (stage 3a/3b), atherosclerotic cardiovascular disease
- Musculoskeletal (MSK): Chronic musculoskeletal pain
- Behavioral Health (BH): Depression and anxiety
Participating organizations must manage all qualifying conditions within a track, delivering care through clinician consultations, lifestyle and behavioral support, medication management, diagnostic testing, and/or use of devices authorized by the Food and Drug Administration (FDA). Care may be provided in-person, virtually, asynchronously, or via other technology-enabled methods.
Organizations enrolling in ACCESS must be Medicare Part B providers or suppliers, comply with applicable licensure, HIPAA, and FDA requirements, and designate a physician Medical Director responsible for clinical oversight and compliance.
Outcome-Aligned Payments and Performance Measurement
ACCESS replaces traditional FFS payments with OAPs—recurring payments tied to achieving patient-specific health targets, including clinical measures and patient-reported outcomes. The model includes an initial year of care management, followed by an optional one-year continuation period at a reduced payment rate.
Participants will submit monthly OAP billing using new, track-specific G-codes. Payments will be distributed on a quarterly basis, with half of the OAP distributed up-front, and the withheld half distributed with final reconciliation adjustments after the 12-month care period is completed.
Payments are adjusted based on the overall proportion of an organization’s patients meeting outcome targets. For 2026, if outcome attainment exceeds the target for 50% or more of patients, the participant will earn the full OAP. However, if attainment is less than 50%, the OAP would be downward adjusted proportionally.
The Clinical Outcome Adjustment measures will be reported to CMS via a Fast Healthcare Interoperability Resources® (FHIR®)-based Reporting API and include:
- Blood pressure reduction or control (eCKM, CKM)
- Low-density lipoprotein cholesterol (LDL-C) reduction or control (eCKM, CKM)
- Weight reduction or control (eCKM, CKM)
- Hemoglobin A1c reduction or control (eCKM, CKM)
- Kidney health monitoring (CKM)
- Musculoskeletal pain: improvement in pain and function (MSK)
- Depression reduction or remission (BH)
- Anxiety reduction or remission (BH)
- Overall function: improvement or maintenance (BH)
- Patient global impression of change (BH, MSK)
Additionally, CMS will apply a Substitute Spend Adjustment to incentivize participants to minimize avoidable duplicative services. For 2026, the substitute spend threshold—the percentage of aligned beneficiaries who did not receive listed substitute services from other Medicare providers or suppliers for the same condition during their ACCESS care period—is 90%. If a participant’s rate is less than 90%, the OAP would be downward adjusted proportionally, capped at negative 25%.
CMS will apply risk adjustment and provide a fixed payment enhancement for rural patients in order to promote equitable access.
CMS will monitor clinical performance and publicly report risk-adjusted outcomes to promote transparency and informed patient choice.
Primary Care Co-Management
Primary care providers (PCPs) and referring clinicians can refer patients to ACCESS organizations and receive regular electronic updates on patient progress. A new co-management payment allows PCPs to bill for documented review and coordination activities, strengthening collaboration and care continuity.
Patient Choice
Patients voluntarily enroll directly with ACCESS organizations or through referral, retaining all Medicare benefits and the freedom to see any Medicare provider. ACCESS organizations may waive standard Medicare cost-sharing, but participation in this benefit is voluntary.
Next Steps
Complete details can be found in the Request for Applications. Interested organizations should complete the Interest Form to receive ongoing updates from CMS. Applications for the first performance period beginning July 1, 2026, are due by April 1, 2026, with later applications considered for a January 1, 2027, start.
We’re Here to Help
For guidance on the ACCESS Model, including application support, strategic planning, financial projections, compliance, and operational readiness, contact your firm professional.