The CMS ACCESS Model Update and Payment Rates
•February 13, 2026
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Why It Matters
Understanding the ACCESS Model is crucial for health systems and digital health firms because it reshapes reimbursement incentives, rewarding measurable health improvements over volume of services. The model’s design pushes providers toward integrated, technology‑enabled care pathways and could set a template for future Medicare and commercial chronic‑care payment reforms, making early adoption a strategic advantage.
The CMS ACCESS Model Update and Payment Rates
The Centers for Medicare & Medicaid Services (CMS), through its Center for Medicare and Medicaid Innovation (CMMI), has released detailed payment and performance guidance for the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, set to launch on July 5, 2026 and run through December 31, 2027. ACCESS represents a significant departure from fee-for-service reimbursement for chronic disease management, introducing a recurring, outcome-linked payment structure that ties Medicare dollars directly to measurable clinical improvement. The model targets four clinical domains: 1. early cardio-kidney-metabolic disease, 2. advanced cardio-kidney-metabolic disease, 3. musculoskeletal conditions, and 4. behavioral health. The model pays participating organizations a fixed annual amount per beneficiary, with up to half of that payment withheld pending demonstrated results.
The model’s core mechanism is the Outcome-Aligned Payment (OAP), a per-beneficiary annual allowed amount that covers integrated care management for qualifying conditions. Unlike traditional chronic care management codes that reimburse for time or activity, OAPs are calibrated to the expected resource intensity of each clinical track and are conditioned on achieving specific clinical and patient-reported outcome targets. Medications, labs, imaging, and durable medical equipment are explicitly excluded from the OAP and continue to be billed separately under standard Medicare payment methodologies by financially unaffiliated entities. This design effectively creates a care management layer that sits atop existing Medicare coverage, funding the coordination, monitoring, and patient engagement activities that drive outcomes rather than the commoditized inputs themselves.
The TL;DR is that the payments are lower than expected and clearly focused on software and mobile app-based technologies rather than hardware heavy remote monitoring-like models.
Clinical Track Structure and Requirements
ACCESS organizes participation into four clinical tracks, each with its own payment tiers, qualifying conditions, and outcome measures.
The Early Cardio-Kidney-Metabolic (eCKM) Track targets beneficiaries with risk factors such as hypertension, obesity, prediabetes, and dyslipidemia before they progress to established cardiovascular or kidney disease. Required OAP measures include blood pressure reduction or control (systolic target below 130 mm Hg or a 15 mm Hg reduction), weight reduction or control (BMI below 30 or 5% weight loss), HbA1c monitoring (with end-of-period targets only for beneficiaries with prediabetes), and LDL-C management (with targets only for those with dyslipidemia). For beneficiaries without the specific comorbidity triggering a measure, success is defined simply as submitting a valid baseline value—a pragmatic design choice that avoids penalizing participants for managing lower-acuity patients while still generating population-level data.
The Cardio-Kidney-Metabolic (CKM) Track covers beneficiaries with established disease, including diabetes, atherosclerotic cardiovascular disease (ASCVD), and chronic kidney disease (CKD). It shares the same blood pressure and weight measures as eCKM but sets distinct HbA1c targets for diabetes (final HbA1c below 7.5% or 1 percentage point reduction) and adds a more aggressive LDL-C control target for ASCVD patients (below 70 mg/dL). The CKM track also requires baseline reporting of eGFR and uACR for beneficiaries with diabetes or CKD, though no performance targets are set for kidney function markers—CMS acknowledges insufficient clinical consensus to define a meaningful improvement threshold for these metrics.
The Musculoskeletal (MSK) Track is designed around functional restoration within a single 12-month care period and does not include a Follow-On Period. Participants select a patient-reported outcome measure (PROM) matched to the beneficiary’s anatomical site of pain—PROMIS Physical Function and Pain Interference for general or multi-site pain, the Oswestry Disability Index for low back pain, the Neck Disability Index for neck pain, QuickDASH for upper extremity conditions, and KOOS JR or HOOS JR for knee or hip osteoarthritis. The MSK track notably establishes no control targets, only minimum improvement thresholds, reflecting a philosophy that incentivizing meaningful functional gains is more appropriate than requiring maintenance of any particular symptom level. All MSK beneficiaries must also report a pain intensity measure (NRS or PROMIS Pain Intensity 1a) and the Patient Global Impression of Change (PGIC).
The Behavioral Health (BH) Track uses the PHQ-9 for depression and GAD-7 for anxiety as its primary outcome measures. Beneficiaries must score at least 10 on the relevant instrument to enter the Initial Period; those scoring below 10 may enter directly into the Follow-On Period if they have a documented history and provider referral. Targets require either maintaining scores below 10 (control) or achieving a 5-point reduction on PHQ-9 or 4-point reduction on GAD-7 (minimum improvement). The BH track also collects the PGIC and optionally the WHODAS 2.0 12-item functional assessment, with CMS signaling its intent to develop a future functional improvement measure for behavioral health.
Payment Rates and Financial Architecture
The payment structure is tiered by track and care period. Annual allowed amounts for the Initial Period (e.g., when expected resource needs are highest due to onboarding, baseline assessment, and initial clinical improvement) are $360 for eCKM, $420 for CKM, $180 for MSK, and $180 for BH. Follow-On Period rates, applicable when a beneficiary is continuing established care, are exactly half: $180 for eCKM, $210 for CKM, and $90 for BH. MSK has no Follow-On Period. These allowed amounts include both the 80% Medicare program payment and 20% beneficiary coinsurance, which participants may uniformly waive (this is a big deal to ensure access to the program for lower income individuals). Rural beneficiaries in the eCKM or CKM Initial Period receive an additional $15 fixed payment to offset connected device distribution costs.
CMS issues monthly payments equal to one-twelfth of the Medicare portion of the annual OAP, but caps cumulative monthly disbursements at 50% of the annual Medicare amount. The remaining 50% is withheld and reconciled after the 12-month care period through two adjustment mechanisms. The Clinical Outcome Adjustment evaluates whether the participant’s Outcome Attainment Rate (OAR), or the share of attributed beneficiaries who meet all required OAP measure targets, meets the Outcome Attainment Threshold (OAT), set at 50% for the initial effective period. The Substitute Spend Adjustment reduces OAPs when attributed beneficiaries receive defined substitute services from other Medicare providers above the 90% Substitute Spend Threshold.
When a beneficiary is aligned to multiple tracks with the same participant, CMS applies a 5% discount to the monthly OAP of the lowest-cost track during overlapping months, reflecting administrative efficiencies. This discount applies only to the Medicare portion and is not passed through to beneficiary coinsurance.
Payment Exclusivity and Substitute Service Implications
A critical feature of the ACCESS Model is how it interacts with other Medicare reimbursement. The Substitute Spend Adjustment creates a direct financial consequence when beneficiaries receive services from other providers that CMS considers substitutes for ACCESS care. For the BH track, these substitute services include digital health management device supply codes (G0552, G0553), psychiatric diagnostic evaluations (90791, 90792), remote therapeutic monitoring patient education and setup (98975), and initial psychiatric collaborative care management (99492). The eCKM, CKM, and MSK substitute service lists are defined in the original RFA.
To trigger the adjustment, these services must be furnished by another Medicare-enrolled provider during the beneficiary’s care period with a principal diagnosis matching a qualifying ACCESS condition. The mechanism is designed to penalize fragmentation: if a beneficiary enrolled in ACCESS BH simultaneously initiates psychiatric care management with an outside provider for the same condition, the ACCESS participant’s payment is reduced. This creates a strong incentive for ACCESS participants to serve as the primary locus of chronic disease management for their attributed conditions, and it effectively limits the degree to which overlapping Medicare reimbursement can be claimed for the same clinical need.
The model also requires baseline OAP measures within 60 days of alignment, quarterly reporting on a 70-to-110-day cycle, and end-of-period reporting by day 425. Early success reporting is permitted (e.g., up to 90 days early for eCKM/CKM and 180 days early for BH/MSK), and once achieved, cannot be negated by subsequent clinical worsening. This asymmetry rewards early intervention while protecting participants from the inherent volatility of chronic disease trajectories.
Implications for the Market
ACCESS represents CMS’s most structured attempt to create a scalable, outcome-conditioned payment for chronic disease management outside of traditional accountable care organizations. By publishing standardized G-codes, FHIR-based reporting APIs, and reference documents for payment adjustments, CMS is explicitly inviting multi-payer adoption, including Medicare Advantage, Medicaid, and commercial plans. Indeed, other major health plans are joining the ACCESS model. The model’s architecture suggests a future where chronic care management payments function less like fee-for-service billing codes and more like capitated outcome contracts, with the clinical track structure providing the specificity that broad-based capitation has historically lacked. For organizations considering participation, the financial calculus hinges on their ability to achieve the 50% OAT across their attributed population while keeping substitute spend below the 90% threshold, a dual optimization problem that will favor integrated, technology-enabled care delivery platforms.
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