ACCESS Demo: The Future?

For my entire career (and that's a really long stretch), insurers, the government, and medical groups have been trying to figure out how to pay for better outcomes. The problem is that no one really knows how to define 'better'. Here we go again. The Centers for Medicare & Medicaid Services (“CMS”), through the CMS Innovation Center (“CMMI”), has announced the ACCESS Model—Advancing Clinical Care, Equity and System Sustainability, a demonstration model that aims to create an outcomes-based payment pathway for chronic-condition management, care coordination, and health-related social needs (“HRSN”) integration. The ACCESS Model claims to be different from other models. This is because it establishes a structure that allows a wide range of Medicare Part B-enrolled organizations—including physician practices, digital chronic-care platforms, home-based providers, and community-supported care organizations—to receive Medicare payments tied directly to clinical and equity-related outcomes. CMS has also taken another step by allowing direct beneficiary enrollment, removing historical dependence on ACO alignment or claims-based patient or case-based attribution.

Model Overview and Rationale

CMS describes the ACCESS Model as part of a broader effort to address persistent gaps in Medicare’s chronic-care infrastructure. The ACCESS Model is designed to streamline these workflows by offering a unified, outcomes-based payment approach that holds organizations accountable for improving chronic-condition outcomes, reducing avoidable healthcare interventions, and addressing social determinants of health.

The policy rationale is driven by four objectives:

• Empower people to achieve their health goals by improving patient access to new technology-supported care options to manage their chronic conditions.
• Expand clinicians’ ability to offer innovative, technology-enabled care through a straightforward payment pathway.
• Ensure that technology-supported care is clinician-guided, accountable, and coordinated.
• Promote transparency by publishing risk-adjusted health outcomes of technology-supported care so patients and referring clinicians can make informed choices

Timeline and Model Clinical Conditions

The voluntary model focuses on conditions affecting more than two-thirds of people with Medicare, including high blood pressure, diabetes, chronic musculoskeletal pain, and depression. It will run for 10 years beginning July 1, 2026. Other conditions may be added during this period and beyond.

Participation Pathways and Organizational Eligibility

A central feature of ACCESS is its broad eligibility standard. Any Medicare Part B-enrolled organization may apply to participate, subject to compliance with model requirements. CMS anticipates participation from primary care practices, multispecialty groups, home- and community-based providers, and technology-enabled chronic-care management companies.

Every ACCESS Organization must designate a physician Clinical Director responsible for clinical governance and oversight of care-management standards.

Beneficiary Alignment and Direct Enrollment

One of the most significant departures from prior Innovation Center models is direct beneficiary enrollment. CMS indicates that beneficiaries may: (i) enroll directly with an ACCESS Organization; or (ii) enroll after a referral from a primary care practitioner or other qualified practitioner. This mechanism allows organizations to engage Medicare beneficiaries without relying on claims-based attribution or ACO assignment.

Payment Methodology and Patient Out-of-Pocket

ACCESS Organizations are not required to assume downside financial risk. CMS intends the model to function as an outcomes-based structure rather than a risk-bearing total cost-of-care arrangement. Bear in mind that the government and other managed care organizations have been trying to achieve outcomes-based payment for a long time. CMS describes the ACCESS Model as an outcomes-based payment framework. Payments will depend on achieving measurable improvements in chronic-condition outcomes, patient engagement, and HRSN (Health-related Social needs) resolution. ACCESS is intended to align reimbursement with longitudinal outcomes rather than discrete fee-for-service activities.

CMS intends to offer the CMS-sponsored model patient incentive safe harbor (42 CFR § 1001.952(ii)(2)) to ACCESS participants who wish to forego the collection of beneficiary cost-sharing as a beneficiary engagement incentive. ACCESS Participants may indicate in the model application whether they will collect or forego cost-sharing. Participants must apply this policy uniformly to all beneficiaries, consistent with the requirements to be outlined in the applicable governing documentation and all applicable laws and regulations. If an ACCESS Participant elects to collect participating beneficiary cost-sharing, they must clearly disclose the expected beneficiary payment amount before beneficiary enrollment.

There is no cost-sharing for the separate co-management payment billed by primary care or referring clinicians when they review and coordinate care with ACCESS participants. This supports stronger collaboration between technology-enabled care teams and traditional providers.

ACCESS Co-Management Payments

Clinicians who co-manage ACCESS beneficiaries with an ACCESS participant will be able to bill a new ACCESS model co-management service for documented review of ACCESS updates and care coordination activities. The service will be paid approximately $30 per service, subject to the geographic adjustment and standard Medicare payment adjustments.

To bill the co-management code, the consulting clinician must review the ACCESS care update and place a brief written note in the electronic health record (EHR) documenting the assessment and any care-coordination action, such as:

• a medication change or reconciliation
• an updated problem list
• monitoring instruction
• a referral

Clinicians who assist a beneficiary with onboarding and initial setup activities may also bill the co-management code with a CMS-specified modifier on the first bill for that beneficiary, to receive an additional payment of approximately $10, subject to the adjustments described above. The payment will be limited to once every four months per beneficiary per track, up to approximately $100 per year.

As noted above, there will not be Medicare Part B beneficiary cost sharing for this co-management service, and advance consent from beneficiaries will not be required.

CMS will provide the ACCESS Co-Management Payment G-code, modifier, and additional billing guidance in 2026.

Performance Measurement, Health Equity Requirements, and Reporting

The ACCESS measurement structure will center on chronic-condition outcomes, patient engagement metrics, functional status improvement, and the resolution of identified social needs.

CMS highlights several required capabilities, including:

• HRSN screening using CMS-approved tools;
• tracking and documenting closed-loop referrals to community-based organizations;
• stratification of outcomes across demographic and equity categories; and
• standardized reporting on engagement and clinical progress.

Participants must exchange data with CMS, practitioners and community partners using CEHRT or comparable technology.

ACCESS Tools Directory

In addition to the ACCESS participant directory, CMS plans to host a resource within the ACCESS application and participant portal, called the ACCESS Tools Directory, to help participants identify optional software and hardware tools that may support model participation and compliance.

Relationship with MSSP ACOs, ACO REACH, and Other Medicare Models

The Access Model is intentionally designed to operate in parallel to, not in place of, MSSP ACOs and other Innovation Center models. Whereas ACOs rely on alignment, benchmarking and shared savings methodologies, the Access Model is focused on outcomes and social-needs resolution for enrolled beneficiaries. ACO participation is “preferred” but not required.

The Access Model thus introduces a dual-pathway structure in which ACOs retain population-level accountability while ACCESS Organizations manage condition-specific or patient-selected engagement cohorts.

Key CMS Resources

If you wish to review CMS’s primary materials, the most relevant publicly available resources on the ACCESS Model are:

CMS Innovation Center – ACCESS Model Page

ACCESS Model – Technical Frequently Asked Questions